Form 516-0-1 Federal Hotel and Motel Fire Safety Declaration Form

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
FEDERAL HOTEL AND MOTEL FIRE SAFETY DECLARATION FORM

OMB Control Number: 1660-0068
Expiration: 8/31/2018

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 15 minutes per response for property owners/managers and 20 minutes
per response for States. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and submitting this form. This collection of information is voluntary. 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 the burden to: Information Collections Management, Department of Homeland
Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project
(1660-0068). NOTE: Do not send your completed form to this address.
Use this form to report your property's compliance with the Hotel and Motel Fire Safety Act of 1990 (P.L. 101-391).
Compliant properties will be added to the National Master List (NML).
This form is being submitted to (Check one):
Change Listing FEMA #:

Add a previously unlisted property
Property type (Check one):

Hotel / Motel

Delete Listing FEMA #:

Bed & Breakfast

Apartment Building

College / University

Other

Property Information (Bolded information is required.)
Property Name

Federal Employer ID Number (EIN)

General Manager

DRAFT

Street Address

Zip Code

P.O. Box

State

Phone Number

Fax Number

Web Site Address

Property E-mail Address

Smoke Alarms Check One:

City

YES

NO

Each guest room is equipped with at least one hard-wired single station smoke alarm installed in accordance with National Fire Protection
Association (NFPA) Standard 72.
Note: Smoke alarms that are solely battery-operated do not qualify.
Automatic Sprinkler Systems (required unless three stories or fewer in height)
Number of Floors:
1. If sprinkler installed on or after October 25, 1992 -- This property has an automatic sprinkler system installed in accordance with
NFPA Standard 13 or 13R, whichever is appropriate, in accordance with the requirements of the Act.
2. If sprinkler installed before October 25, 1992 -- This property has an automatic sprinkler system installed in compliance with an
applicable standard (adopted by the governmental authority having jurisdiction, and in effect, at the time of installation), provided such
standard required the placement of a sprinkler head in the sleeping area of each guest room.
3. This property does not exceed three stories in height and is therefore exempted from the Act's automatic fire sprinkler requirements.

FEMA Form 516-0-1 (11/17)

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E-mail, Fax or Mail the completed form to the United States Fire Administration
I hereby attest that the information supplied on this form is true and accurate to the best of my knowledge and belief. Therefore,
(name of property) is entitled to be included in the National Master List (NML) of public accommodations compiled by the United States Fire
Administration. I understand that this information is subject to verification by Federal, state, and local authorities, and that I am subject to fines
of up to $ 10,000 and/or imprisonment for up to five years if I knowingly make false or fraudulent statements to the government.

Print Name (contact)

Signature (Not required for e-mail.)

Date

Title

Organization

Phone Number

E-mail

Fax Number

For more information contact the U.S. Fire Administration, 16825 S. Seton Ave. Emmitsburg, MD 21727 Tel. 301-447-1263,
[email protected], Fax 301-447-1102

DRAFT

FEMA Form 516-0-1 (11/17)

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