Form FEMA Form 090-0-2 FEMA Form 090-0-2 Application for Community Disaster Loan

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
APPLICATION FOR FEDERAL ASSISTANCE
(Application for Community Disaster Loan)

OMB Control No. 1660-0083
Expires August 31, 2015

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1 hour per response. The burden estimate includes the time for reviewing instructions, searching
existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. This collection of information is required to
obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send
comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472-3100 and Paperwork Reduction Project (1660-0083).
NOTE: Do not send your completed form to the above address.
PRIVACY NOTICE
This information is being collected under the authority of Section 417 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288,
as amended, (42 U.S.C. 5121-5207), and 44 CFR, § 206.364. DHS/FEMA will use this information to provide operational funding to help local governments that
have incurred a significant loss in revenue, due to a major disaster, that has or will adversely affect their ability to provide essential municipal services. The
information will be used by and disclosed to DHS personnel and contractors, state government officials, or other agents who need the information to assist in
activities related to disaster relief. In addition, the information on this form may be disclosed as generally permitted under the Freedom of Information Act, as
amended (5 U.S.C. § 552). Furnishing this information is voluntary; however, failure to furnish the requested information may delay or prevent the completion of
your loan application and disbursement.

1. TYPE OF SUBMISSION
(Application)
Construction

2. DATE SUBMITTED

APPLICANT IDENTIFIER

3. DATE RECEIVED BY STATE

STATE APPLICANT IDENTIFIER

4. DATE RECEIVED BY FEDERAL
AGENCY

FEDERAL IDENTIFIER

(Preapplication)

Loan

Construction

Non-Construction

Non-Construction

5. APPELLATION INFORMATION
a. LEGAL NAME

b. ORGANIZATIONAL UNIT

c. ADDRESS (Give city, county, state, and zip code)

d. NAME AND TELEPHONE NUMBER OF THE PERSON TO BE
CONTACTED INVOLVING THIS APPLICATION (Give area code)

6. EMPLOYER IDENTIFICATION NUMBER (EIN)
7. TYPE OF APPLICANT (Enter appropriate letter in box) *
(* First see 44 CFR 206.363(a))
a. State
b. County
c. Municipal
d. Township
e. Interstate
f. Intermunicipal
g. Special District

8. TYPE OF APPLICATION
LOAN

h. Independent School District
i. State Controlled Institution of Higher Learning
j. Private University
k. Indian Tribe
l. Individual
m. Profit Organization
n. Other (Specify)

NEW

CONTINUATION

REVISION
If Revision, enter appropriate letter(s) in box(es)
a. Increase
b. Increase Duration

c. Decrease Award
d. Decrease Duration

Other (Specify)

9. NAME OF FEDERAL AGENCY

10. CATALOG OF FEDERAL
DOMESTIC ASSISTANCE NUMBER:

FEDERAL EMERGENCY MANAGEMENT AGENCY
11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:

TITLE: DISASTER ASSISTANCE
12. AREAS AFFECTED BY THE PROJECT (Cities, counties, states,
etc.)

APPLICATION FOR COMMUNITY DISASTER LOAN

LOCAL GOVERNMENT

13. PROPOSED PROJECT
START DATE

ENDING DATE

FEMA FORM 090-0-2 (01/15)

14. CONGRESSIONAL DISTRICT OF:
a. APPLICANT

b. PROJECT

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APPLICATION FOR FEDERAL ASSISTANCE
(Application for Community Disaster Loan)
a. Federal

$

b. Applicant

$

c. State

$

d. Local

$

e. Other

$

f. Program

$

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372
PROCESS?
.00
a. YES. This application/preapplication was made available to the state executive order
12372 process for review on:
.00
DATE
.00
b. NO.
Program is not covered by E. O. 12372
.00
Or program has not been selected by state for review
.00
Review waived per FEMA - State agreement for major disaster
.00 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBIT?

g. TOTAL

$

.00

15. ESTIMATED FUNDING

a. YES, (If "YES" attach an explanation)

NO

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT.
THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL
COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. TYPED NAME OF AUTHORIZED REPRESENTATIVE

b. TITLE

d. SIGNATURE OF AUTHORIZED REPRESENTATIVE

c. TELEPHONE No.
DATE

Certification
A. The State certifies that the applicant possesses the legal authority to apply for the loan in the amount requested.
The Applicant Certifies
B. That it possesses the legal authority to apply for the loan amount requested.
C. That a resolution, motion or similar action has been duly adopted as an official act of the applicant, city counsel or other governing body, authorizing the filling
of the loan application, including all understandings and assurances contained therein, and directing and authorizing the person identified as the official
representative of the applicant to act in connection with the application and to provide such additional information as may be requested.
D. That (to the best of his/her knowledge and belief) the Community Disaster Loan herein requested is eligible in accordance with the criteria contained in 44
Code of Federal Regulation, Part 206, and applicable FEMA/EP&RD (DAP) Handbooks and guidelines.
E. That this is the legal entity responsible under law for the repayment of the Community Disaster Loan and interest thereon or accepts such responsibility.
F. That all information given by it herein is, to the best of my knowledge and belief, true and correct.
Assurances
G. The States agree to provide technical assistance in review of records of the Applicant which provide the basis for the application for the loan and for loan
cancellation. The State further agrees to provide technical assistance in processing and administering the loan
The Applicant Certifies
H. That it complies with all Federal statues relating to nondiscrimination. These include but are not limited to: (1) Title VI of the Civil Rights Act of 1964 (P.L.
88-352) which prohibits discrimination on the basis of race, color or national origin; (2) Title IX of the Education Amendment of 1972, as amended (20 U.S.C.
1681-1683, and 1685-1686) which prohibits discrimination on the basis of sex; (3) Section 504 of the Rehabilitation Act of 1973, as amended (29) U.S.C. 794)
which prohibits discrimination on the basis of handicaps; (4) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107) which prohibits
discrimination on the basis of age (5) the Drug Abuse Office and Treatment Act of 197 2 (P.L. 93-255) as amended, relating to nondiscrimination on the basis of
drug abuse; (6) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L.91-616) as amended, relating to
nondiscrimination on the basis of alcohol abuse or alcoholism; (7) 523 and 527 of the Public Health Service Act of 19 12 (42 U.S.C 290 dd-3 and 290 ee-3), as
amended, relating to confidentiality of alcohol and drug abuse patients records; (8) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et. seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (9) any other nondiscrimination provision the specific statue(s) under which application for
Federal assistance is being made; and (10) the requirements on any other nondiscrimination Statue(s) which may apply to the application.
I. That this assurance is given in consideration of and for the purpose of obtaining any and all Federal grants, loans reimbursements, advances, contracts,
property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by EP&RD/FEMA, that such Federal assistance will be
extended in reliance on the representations an agreements made in the full assurance and that the United States shall have the right to seek judicial enforcement
of this assurance. This assurance is binding on the Applicant, its successors, transferrers, and assignees, and the person or persons whose signatures appears
on the reverse are authorized to sign this assurance on behalf of the Applicant.
J. That it give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to
and the right to examine all records, books, papers, or documents related to the assistance, and will establish a proper accounting system in accordance with
generally accepted accounting standards or agency directives.
K. That the loan funds do not duplicate funding provided from any other source.
L. That it causes to be performed the required finical and compliance audits in accordance with the Single Audit Act of 1984.

FEMA FORM 090-0-2 (01/15)

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APPLICATION FOR FEDERAL ASSISTANCE
(Application for Community Disaster Loan)

I. ESTIMATE OF REVENUE LOSS AND DISASTER-RELATED EXPENSES
(5)
(1)
(2)
(3)
(4)
THIRD
FISCAL YEAR FISCAL YEAR
FIRST
SECOND
PRECEDING
(FY)
SUCCEEDING SUCCEEDING SUCCEEDING
DISASTER
OF DISASTER
20

20

20

20

(6)
TOTAL
(2 + 3 + 4 + 5)

20

A. Annual Operating Budget 1/
B. Estimated Revenue Loss 2/
C. Disaster Related Expenses 3/
D. Total (B + C)
E. Percent (D/A X 100)
F. 25% OF (A)
1/Provide copy of Operating Budget for fiscal year (FY) of disaster, and explanation for significant future FY increases/decreases.
2/Provide supporting information indicating how figures in the revenue/expense estimates were developed.
DURATION OF LOAN
AMOUNT OF LOAN REQUESTED (Not to exceed
TO
25% of Annual Operating Budget for Disaster Year) FROM

APPLICANT'S FISCAL YEAR ENDS

II. OPERATIONAL RESULTS (For Year of Disaster * and Prior Three Fiscal Years)
THIRD PRIOR
SECOND PRIOR
FISCAL YEAR PROCEEDING FISCAL YEAR (FY) OF
DISASTER 20
DISASTER
20
20
20
A. Cash Balance (or Deficit) from
Previous Fiscal Year (include
investments)
B. Cash Balance (or Deficit) at End of
Fiscal Year
C. Liabilities at End of Fiscal Year
D. Ratio of B. to C.
E. Attach audited financial statements for each of the four prior fiscal years
III. DEBT HISTORY
A. Postponements and Defaults. Have there been postponements or defaults in any payments of principal or interest on past or current
indebtedness by the applicant?
YES

NO If, yes, explain the circumstances, corrective action taken and pertinent dates. Attach explanation.

B. Outstanding bonded indebtedness. List below each medium and long-term indebtedness currently outstanding and such short-term
indebtedness as may have a bearing on the loan requested. If for outstanding indebtedness of a particular series, there are two or more interest
rates, show the average interest rate on obligations still outstanding.
NAME OF
OUTSTANDING INDEBTNESS

FEMA FORM 090-0-2 (01/15)

AMOUNT OUTSTANDING
AS OF

DATE
OF ISSUE

20

AVERAGE
INTEREST RATE

TOTAL TERM
OF ISSUE

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.
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APPLICATION FOR FEDERAL ASSISTANCE
(Application for Community Disaster Loan)

C. Federal Loans. If any bonds or other instruments of indebtness are presently held by the U.S. Government, specify the agency and the
instruments of indebtness.
IV. TAX ASSESSMENT (FY of Disaster + 3 Prior FY's)
B. PAYMENT AGAINST ASSESSMENT (Month, day, year)

A. PROPERTY ASSESSMENT AS OF (Month, day, year)
THIRD PRIOR

SECOND PRIOR

FY 20

C. Real Property Taxes

FY 20

FISCAL YEAR
PRECEDING DISASTER
FY 20

FISCAL YEAR (FY) OF
DISASTER
FY 20

1. Market Value ($)
2. Assessment Ratio ( % )
3. Valuation ( $ = 1 x 2)
4. Tax Rate ( $ = 3 x 4)
5. Tax Levy ( $ = 3 x 4)
6. Taxes Collected
V. OTHER INFORMATION

A. Other Federal Assistance. Are you requesting or receiving assistance from the Federal Government for a reason which is similar to the one
for which assistance is requested in this application?
YES
NO If yes, provide the name of the other agency and project
number
B. Has the loan been approved by the City Counsel?
YES
NO
If yes, give date of loan
C. Does a State agency have to approve the proposed debt?
If yes, identify the agency and briefly explain its
YES
NO
authority.
D. Is this loan requested for
YES

NO

within the applicant's ceiling for financial obligations fixed by law or by local government body?

$

If No, attach explanation.

E. Name and Address of Applicant's Chief Fiscal Officer (Include zip code)
Title of Applicant's Chief Fiscal Officer

PHONE No. (Include area code)
CERTIFICATION

The Applicant certifies to t e best of his/her knowledge and belief that the debt in the loan application is correct and that the loan is legal and
has been duly authorized by the governing body of the applicant. (Penalties for false and misleading information are covered by Federal laws)
DATE

SIGNATURE

NAME AND TITLE OF APPROVING OFFICIAL

FORWARDED
NAME AND TITLE OF APPROVING OFFICIAL (Governor's Authorized
Representative)
FOR FEMA USE ONLY

RECOMMENDED:

NAME AND TITLE OF APPROVING OFFICIAL (FEMA Regional Director)

SIGNATURE

APPROVAL

FEMA FORM 090-0-2 (01/15)

DISAPPROVAL

SIGNATURE

DATE

DISAPPROVED

APPROVED IN THE AMOUNT OF $
NAME AND TITLE OF APPROVING OFFICIAL (EP&RD Regional Dir.)

DATE

SIGNATURE

DATE

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