Form FEMA Form 119-0-1 FEMA Form 119-0-1 Application for Surplus Federal Real Property Public Ben

SURPLUS FEDERAL REAL PROPERTY PUBLIC BENEFIT CONVEYANCE PROGRAM
APPLICATION AND GUIDANCE
FOR FEDERAL EMERGENCY MANAGEMENT RESPONSE AND FIRE AND RESCUE USE
ELIGIBIITY
The fifty States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the Virgin Islands, the Federated States
of Micronesia, the Marshall Islands, Palau, and the Northern Mariana Islands.
DEADLINE
The completed application is due within 60 days of the announcement date on the NOTICE OF SURPLUS DETERMINATION (or within 30
days of the expiration date of the NOTICE OF SURPLUS DETERMINATION).
CONTACT INFORMATION
PBC/BRAC Coordinator
Federal Emergency Management Agency
Support Services and Facilities Management Real Property Division
500 C Street, SW, Washington, DC 20472
202-646-2605 (office)
202-646-4668 (fax)
[email protected]
SURPLUS FEDERAL REAL PROPERTY PUBLIC BENEFIT CONVEYANCE (PBC)
AND BASE REALIGNMENT AND CLOSURE (BRAC) PROGRAMS
BACKGROUND
Excess Federal Real property is defined as property that is no longer mission critical to the needs of the Federal government. The conveyance
and disposal of excess real property is governed by the Federal Property and Administrative Services Act of 1949 (Property Act) as amended,
40 U.S.C. 541, et. seq., and applicable regulations (Title 40 U.S.C. 553 and 41 CFR parts 102-75.750 through 102-75.815). Under the
sponsorship of Federal Emergency Management Agency (FEMA), the Act gives the Administrator of the General Services Administration
(GSA) authority to convey Federal real and related personal property (without monetary consideration) to units of State and local government
for emergency management response purposes, including fire and rescue services.
PBC - GSA and other Federal and local government land holding agencies are tasked with regularly surveying government-owned
properties to determine if properties are being fully utilized, under utilized, or not put to best use. GSA reviews the resulting reports
and makes a determination as to the availability of these properties. If available, GSA categorizes them as excess and the properties
are offered to other Federal government agencies for acquisition*. If no other Federal agency expresses an interest in the excess
properties, the properties are then deemed surplus and are offered to State and local government agencies for acquisition via
negotiated sale or through the vehicle known as public benefit conveyance (PBC). GSA will determine the appropriate program for
which the properties are best suited and will inform the proper sponsoring agency of availabilities. GSA is responsible for enforcing
compliance with the terms and conditions of disposals of property to be used for emergency management response purposes.
BRAC - Under the Department of Defense Base Realignment And Closure (BRAC) Act of 1990, PBC sponsoring agencies, such as
FEMA, work under the auspices of the Office of Economic Adjustment (OEA) and in conjunction with Local Redevelopment
Authorities (LRA) to efficiently utilize military base locations that have been approved for pubic use*. The LRA is responsible for
developing a reuse plan that appropriately balances the needs of the various communities affected by these modifications. OEA
manages and directs the Defense Economic Adjustment Program and coordinates the involvement of other federal agencies and
Local Redevelopment Authorities in assisting communities that may be adversely impacted by such program changes. While GSA
assumes primary administration responsibilities for BRAC properties, final disposition rests solely with DoD.
FEMA
FEMA reviews all applications to make recommendations to the GSA Administrator or the Secretary for Defense, as to whether: (1) the use
proposed by the state or unit of local government meets the requirements of the statute; and/or (2) the environmental impact of the proposed
transfer has been properly assessed under the National Environmental Policy Act (NEPA).
FEMA is also responsible for providing interested parties with an application kit, which requests relevant information so that FEMA can
determine if the proposed use is appropriate and in compliance with applicable Federal laws.
*In 1987, Congress enacted the Stewart B. McKinney Homeless Assistance Act. Title V of this Act made serving the homeless the first priority
for use of all surplus Federal properties, including military installations. The Department of Housing and Urban Development (HUD) reviews all
LRA plans to determine compliance with the statue.
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DISCLAIMER
Please note under 40 U.S.C. 533, the GSA Administrator and/or the Secretary for Defense has final approval authority with respect to any and
all surplus property conveyances.
ELIGIBILITY
States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the Virgin Islands, the Federated States of
Micronesia, the Marshall Islands, Palau, and the Northern Mariana Islands, or any political subdivision or instrumentality thereof, may authorize
applications for conveyance of surplus real property for correctional use or law enforcement purposes.
STIPULATIONS AND COMPLIANCE
The deed of conveyance for each and every Program surplus property, stipulates that all of the subject property must always be used and
maintained for the purpose(s) set forth in the Program application. Periodic inspections of properties will be made by GSA and FEMA to
ensure continuing compliance with the terms and conditions of the conveyance. Recipients can suffer hardship and financial loss when
properties revert back to Federal ownership for noncompliance. For example, if a facility is constructed on property conveyed for Federal
emergency management response use, and is later found, instead, as being used for mental health facility purposes, the recipient would be
deemed in non-compliance and the property would be subject to reversion to the Federal Government. Recipients must coordinate any
proposed deviation, however minor, with FEMA and GSA. Recipients must also file an annual self-certification with their respective regional
GSA representatives stating that their current program of use is consistent with those identified in the application.
NON-DISCRIMINATION CLAUSE
Section 102-75.360: The Grantee covenants for itself, its heirs, successors, and assigns and every successor in interest to the property hereby
conveyed, or any part thereof, that the said Grantee and such heirs, successors, and assigns shall not discriminate upon the basis of race,
creed, color, religion, sex, disability, age, or national origin in the use, occupancy, sale, or lease of the property, or in their employment
practices conducted thereon.
INTERGOVERNMENTAL REVIEW OF FEDERAL PROGRAMS
To foster intergovernmental partnerships between the States and their local governments, your intent to apply for excess Federal property
must be communicated to your State's Single Point of Contact (SPOC) for review as per Executive Order 12372:
https://www.fws.gov/policy/library/rgeo12372.pdf.
To determine if your State participates in this requirement, please visit the following web site at:
https://www.whitehouse.gov/omb/grants_spoc.
APPLICATION
Please complete and sign the attached application and submit with required attachments via e-mail to:
[email protected]
Fax: 202-646-4668 Mail: 500 C Street, SW, Washington, DC 20472
FEMA

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

APPLICATION FOR SURPLUS FEDERAL REAL PROPERTY PUBLIC BENEFIT
CONVEYANCE AND BRAC PROGRAMS FOR EMERGENCY MANAGEMENT USE

OMB Control Number: 1660-0080
Expiration: 11-30-2016

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 5 hours per response. The burden estimate includes the time for reviewing
instructions and searching existing data sources, gathering and maintaining the data needed and completing and submitting the form. You are
not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner on this form. Send
comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections
Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington DC, 20472,
Paperwork Reduction Project (1660-0080). NOTE: Send completed form to Federal Emergency Management Agency, Support Services and
Facilities Management Division, 500 C Street SW, Washington DC 20472.
PRIVACY ACT STATEMENT
AUTHORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records in this system under the authority of the Federal
Property and Administrative Services Act of 1949 (Property Act) as amended, and 40 U.S.C. §§ 541,533, and 41 C.F.R.
102-75.750-102-75.815).
PRINCIPAL PURPOSES: This information is being collected for the primary purpose of processing applications for Public Benefit
Conveyance (PBC) and Base Realignment and Closure (BRAC) programs whereby state, local or tribal governments may acquire federal
surplus property for emergency management purposes at no cost.
ROUTINE USES: The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974,
as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/ALL-002 - Department
of Homeland Security (DHS) Mailing and Other Lists System, 73 Fed. Reg. 71,659 (Nov. 25, 2008), and upon written request, by agreement,
or as required by law.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: The disclosure of information on this form is voluntary; however, failure to
provide the information requested may result in the inability to process applications for excess real property.

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SECTION I - APPLICANT
1. APPLICANT'S NAME
3. ADDRESS

2. ORGANIZATION
4. COUNTY

5. CITY

6. STATE

8. CONGRESSIONAL DISTRICT(S)

9. NAME OF PRINCIPAL POINT OF CONTACT

10. TELEPHONE AND FAX NUMBERS

11. E-MAIL ADDRESS

7. ZIP CODE

SECTION II- ACQUISITION AUTHORITY
1. Identify the State and local government agency that is authorized by law to enter into contracts with the Federal Government for the conveyance of real
property. (Please provide a copy of the State enabling legislation and cite the actual paragraph or portion of the legislation that establishes that authority.)

2. If the above-authorized agency is not the applicant agency, provide written delegation from the authorized agency to procure the requested property.

3. Acquisition Authority: Name, title,
address, telephone number, and e-mail
address of official with legal authority to enter
into contracts with the federal government - >

3a. NAME/TITLE

3b. ADDRESS (Include city, state, and zip code.)

3c. TELEPHONE NUMBER

3d. FAX NUMBER

3e. E-MAIL ADDRESS

SECTION III - PROPERTY INFORMATION

1. PROPERTY IDENTIFICATION* (Name, city, and state)

2. GSA NUMBER (If applicable) OR BASE REALIGNMENT ID NO.

3a. DATE APPLICANT NOTIFIED GSA OR LOCAL
REDEVELOPMENT AUTHORITY (LRA) OF INTEREST
(Please attach notice.)

3b. DATE APPLICANT NOTIFIED 3c. DATE PROPERTY WILL BE
FEMA (Please attach notice.)
AVAILABLE FOR CONVEYANCE

4. DESCRIPTION OF PROPERTY (Attach separate sheet, as necessary.)
a. Provide a legal description of the subject property and identify all buildings, structures, and current use. Attach metes and bounds survey
with aerial photos. Mark property area to be conveyed.
b. Identify the property's current zoning classification.
c. Attach or itemize all inventories (personal property) to be conveyed as described in Notice of Availability.
*Attach copy of Determination of Surplus Announcement or BRAC announcement.

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SECTION III - PROPERTY INFORMATION - continued
5. ASSIGNED FEDERAL GSA OR OEA
PROPERTY SPECIALIST - >

5a. NAME

5b. REGIONAL OFFICE LOCATION

5c. TELEPHONE NUMBER

5d. FAX NUMBER

5e. E-MAIL ADDRESS

If you are seeking a determination for property under the Base Realignment and Closure (BRAC) program, please complete items #6 and #7.
6. BRAC ONLY: APPLICANT'S LOCAL REDEVELOPMENT AUTHORITY (Recognized LRA name, address, telephone & contact person;
please attach copy of final LRA Plan)

7. BRAC ONLY: DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD) DETERMINATION (Please attach letter)
SECTION IV - PROJECT INFORMATION

1. PROJECT TITLE
2. PROPOSAL Provide a detailed description of the applicant's project and include the following information:
a. Describe the applicant's mission, problems to be addressed, and how it will benefit from the proposed PBC.
b. Describe the activities to be conducted (e.g., training), the population the PBC will serve, and the anticipated benefits to that
population
c. Federal Emergency Management Response and Fire and Rescue Renovation: Describe the State, local or national authority
standards or guidelines that will be met in designing , renovating, and operating an emergency management facility and the
process and procedural requirements that must be met to assure compliance. Provide detailed description of design, type, and
size of structure and interior floor plans.
d. Provide a schedule for accomplishing renovation/construction and implementing activities after conveyance.
SECTION V - BUDGET
a. Provide an estimate of the total funds needed to renovate, furnish, and/or remodel requested property or to construct on requested
property and the projected cost to maintain it. (Include monthly upkeep, maintenance, utilities, landscaping, telephone, Internet, etc.)
b. Give source of funds, process to obtain the funds, and projected date of availability of funds.
c. Provide a timetable for acquiring funds and maintaining funding to sustain requested property.
SECTION VI - INTERGOVERNMENTAL REVIEW
a. Applicable. Attach a copy of the cover letter addressed to the applicant's State Single Point of Contact (SPOC) for review.
b. State Single Point of Contact. Attach response from SPOC to above notification.
c. Not Applicable. Applicant's State does not require an Intergovernmental Review.
SECTION VII - ENVIRONMENTAL IMPACT
NATIONAL ENVIRONMENTAL POLICY ACT: Categorical Exclusion Checklist All applicants for surplus property for corrections facility, emergency management,
or law enforcement purposes or use must complete the attached checklist to comply with 41 U.S.C. 102-75.785(d) which states in part: "Any determination that
DOJ or FEMA submits to the disposal agency must provide complete information concerning the correctional facility, law enforcement, or emergency
management response use, including:... (d) The environmental impact of the proposed correctional facility, law enforcement, or emergency management
response use." Complete attached National Environmental Policy Act Categorical Exclusion Checklist.

SECTION VIII - CERTIFICATIONS
1. Equal Employment Opportunity: Applicant agrees that for receiving federal surplus real property, it will not discriminate upon the basis of race, color,
national origin, sex, age, disability, or religion in the use, occupancy, or lease of the property for the period during which the real property is used for the
purpose under which the federal financial assistance is extended.
2. Perpetual Use: Applicant understands that the property transfer is pursuant to 40 U.S.C. 553, and agrees that the property will be used and maintained for
Federal emergency management response purposes in perpetuity and that in the event the property ceases to be used or maintained for the purposes for which
the property was conveyed, all or any portion of the property shall in its then existing condition at the option of the grantor, revert to the grantor.
3. Application Certification: I certify that to the best of my knowledge, the information provided in this application is true and correct and the application has
been duly authorized by the governing body of the applicant.

TITLE

FEMA FORM 119-0-1 (11/16)

PRINTED NAME

CERTIFYING REPRESENTATIVE SIGNATURE DATE

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NATIONAL ENVIRONMENTAL POLICY ACT (NEPA)
CATEGORICAL EXCLUSION CHECKLIST
ADDRESS

PROPERTY
CITY, STATE, AND ZIP CODE

STATEMENT

YES

NO

IF "YES" PROVIDE EXPLANANTION

A. Is the renovation/construction likely to be
inconsistent with any applicable Federal, State, tribal,
or local law, regulation, or standard designed to
protect any aspect of the environment?
B. Is the renovation/construction likely to have results
that are inconsistent with locally desired or designated
plans for the project area or its surrounding area?
C. Is the renovation/construction likely to change the
previous use of the building or property?
D. Will the renovation/construction adversely affect an
important aspect of the natural environment such as a
park, endangered species, or important wildlife
habitat?
E. Will the renovation/construction adversely affect a
significant aspect of the socio-cultural environment?
F. Is the renovation/construction likely to generate
controversy on environmental grounds?
G. Is the renovation/construction likely to result in the
use, storage, release and/or disposal of toxic,
hazardous, or radioactive materials or in exposure of
persons to such materials?
H. Is the renovation/construction part of an ongoing
pattern of renovation/constructions (whether under
the control of the GSA or others) that are cumulative
and likely to have adverse effects on the human
environment?
I. Is the renovation/construction likely to either occur
on a structure that is more than 50 years old or
include ground disturbance of a previously
undisturbed area? If yes, contact your State Historic
Preservation Officer (SHPO) to initiate its review
process.

Attach "No Effect" Letter from SHPO

J. Is the renovation/construction likely to have some
other adverse effect on public health and safety or on
any other environmental media or resources that are
not specifically identified above?
K. Is the renovation/construction either so highly
controversial for environmental reasons or is likely to
cause major adverse impacts that an environmental
impact statement should be initiated rather than an
environmental assessment?
SIGNATURE OF CERTIFYING OFFICIAL

TITLE

FEMA FORM 119-0-1 (11/16)

DATE

AGENCY

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APPLICATION INSTRUCTIONS AND REQUIRED ATTACHMENTS
SECTION I - Applicant/Point of Contact
SECTION II - Acquisition Authority
Provide a copy of the governing legislation enabling applicant to receive or act on behalf of applicant for the purpose of receiving
Federal property. Attach copy and cite.
SECTION III - Property Information
3a. Applicant's Notice of Interest: Attach Notice of Interest to the General Services Administration or Department of Defense.
3b. Applicant's Notice of Interest: Attach Notice of Interest to FEMA.
4. Property's Legal Description: Attach the legal description of subject property and identification of all buildings and structures and
current use(s). Attach list of personal inventory to be conveyed with the property as found in the Notice of Availability. *NOTE: Attach
copy of Determination of Surplus Announcement or DoD (BRAC) announcement.
6. BRAC Only: Attach applicant's Local Redevelopment Authority (LRA) Plan.
7. BRAC Only: Department of Housing and Urban Development's determination in compliance with the Stewart B. McKinney
Homeless Assistance Act. This can be received from your LRA or:
Base Realignment and Closure Coordinator
Department of Housing and Urban Development
Office of Special Need Assistance Programs
451 Seventh Street, SW., Room 7266
Washington, D.C. 20410
202-402-2595 (Office) / 202-401-0053 (Fax)
SECTION IV - Project/Proposal Information
Please submit as an attachment.
SECTION V - Budget
Please submit as an attachment. Applicant must show ability to maintain requested property.
SECTION VI - Intergovernmental Review
Does your State require an Intergovernmental Review? Please check the following web site for your State Point of Contact (SPOC):
https://www.whitehouse.gov/omb/grants_spoc. If your state is listed, submit your application to your SPOC for review, obtain the
SPOC's response, and attach to this application when submitted to FEMA. If your state is not listed, please check "C" for not
applicable.
SECTION VII - National Environmental Policy Act (NEPA)
Read and complete the attached Categorical Exclusion Checklist. Sign and attach supporting documentation as needed.
SECTION VIII - Certifications

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