Form FEMA Form 010-0-10 FEMA Form 010-0-10 Landowner's Authorization Ingress-Egress Agreement

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
LANDOWNER'S AUTHORIZATION
INGRESS-EGRESS AGREEMENT

1. REGISTRATION NO.

OMB Control Number: 1660-0030
Expiration: April 30, 2017

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes 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 mandatory. You are not required to respond to this collection of information unless a valid OMB control number
appears in the upper right corner of 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, Paperwork Reduction Project (1660-0030). Please do not send your completed survey to the above
address.
PRIVACY ACT STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part
206.117.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of obtaining necessary landowner consent to inspect
site, place maintain, deactivate and/or remove temporary housing units provided by FEMA to eligible registered disaster survivors as part of its
direct housing program under a Presidentially-declared disaster.
ROUTINE USE(S): 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/FEMA - 008 Disaster
Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by
law.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent the individual from receiving disaster-related temporary housing assistance.

DRAFT

2. LANDOWNER'S INFORMATION
NAME

3. APPLICANT SITE INFORMATION

NAME

ADDRESS (House No. and Street Name)

SITE ADDRESS (House No. and Street Name)

CITY AND STATE (Include Zip Code)

CITY AND STATE (Include Zip Code)

NOTE: PROVIDE DIRECTIONS AND ATTACH MAP IF
NECESSARY
4. In consideration of the President's Disaster
and the furnishing of a temporary housing
Proclamation of
unit by
(date of declaration)
(DR#)
the United States of America to the above applicant, a disaster victim, and other good and valuable considerations not herein expressly stated,
and intending to be bound hereby, the Landowner (which term shall, for the purposes of this agreement, include the owner of record and any
parties in possession) does hereby agree with the applicant as follows:
PHONE NO. (Include Area Code)

a. The Landowner hereby certifies that he/she is the owner of the above described property and authorizes placement of a temporary
housing unit on his/her land for use of the subject applicant for the temporary housing period established by the United States
Government.
b. The Landowner agrees that no in debt ness of his/hers will become a lien on the said housing unit, and that he/she will not attempt
to restrain the owner of the unit from removing it from the subject property.
c. The Landowner agrees to allow and maintain a route on ingress and egress for placing and removing the temporary housing unit
along and across the subject property to the nearest reasonable access to a public street. This agreement includes the prohibition of
structures and barriers upon the property which would hinder or preclude the normal and usual connecting, parking, placing, hitching,
or removing of the temporary housing unit.
d. The Landowner further agrees to maintain a reasonable route of ingress and egress along and across the property to and from the
temporary housing unit for the applicant.
e. The Landowner has agreed that the following alterations to the property may be made to assure adequate ingress and egress or to
allow for utility
connections to existing utility service on the property. No claims will be filed by Landowner for these actions. (List removal of trees,
shrubs, fences, grading holes in driveway or foundation, etc.) Attach drawing of agreed-upon ingress and egress route.
5. This Agreement shall remain in force for 30 days following termination of occupancy of the temporary housing unit in accordance with
procedures and regulations promulgated by the Government.
6. Site preparation costs will be the responsibility of: (Check one)
The applicant;
Landowner;
Other (specify
Provide details if responsibility is divided:
7. Landowner intends to charge and applicant agrees to pay
FEMA Form 010-0-10 (5/15)

/month rent for use of the property. (Mark "None" if no rent is
to be charged

REPLACES ALL PREVIOUS EDITIONS. (This form was consolidated with FF90-41)

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
LANDOWNER'S AUTHORIZATION
INGRESS-EGRESS AGREEMENT
8. SIGNATURE

DATE

a. OWNER/AGENT
b. APPLICANT
c. WITNESS
GENERAL INFORMATION
a. PURPOSE: The Landlord's Authorization is used to obtain the approval of the owner of a property for the placement and removal of a
mobile unit to be used for temporary housing. The purpose of the Ingress-Egress is to obtain the approval of the owner/agent of a property
through which a mobile unit must travel to reach a private site (generally properties adjacent to the proposed site) to ensure placement and
removal of the unit.

DRAFT

b. RESPONSIBILITY: The applicant is responsible for obtaining the Landowner's Authorization from the owner of the proposed site. In an
ingress-egress situation, the applicant must obtain the Ingress-Egress Agreement from as many of the property owners as necessary to ensure
adequate ingress-egress for the site. The applicant will be provided the form by FEMA.
c. DISTRIBUTION:

Original-Applicant
Copy No. 1-Mobile Home Operations
Copy No. 2-Landowner
Copy No. 3-Applicant
Copy No. 4-(Photocopy) Applicant Assistance
INSTRUCTION FOR COMPLETING FORM

Explain the procedure for placement of a mobile unit and the reasons for requiring the Landowner's Authorization before giving the
applicant this document.
1. Registration Number: To be obtained from applicant Assistance.
2. Landowner Information:
located.

Provide complete name of legal owner of property and current address and telephone number where owner can be

3. Applicant Site Information: Give name and address. Provide detail instructions or map if location is not clear from address.
4. Give detail description of alterations that will be made and attach a clear map of agreed upon ingress-egress route(s).
5. Specify who will have responsibility for site preparation including clearance, provision of utilities, connection of utilities etc. (If If responsibility
is divided, provide detailed explanation).
6. If owner does not intend to charge rent "None" should be marked in the blank provided.
7. Signature/Dates
a. Owner: Signature of individual legally empowered to enter into agreement regarding the property. May be owner or legal agent.
b. Applicant: Signature of head of household or other legally responsible member of household. Individual state laws must be observed
in determining legal responsibility. If adults not related by marriage (i.e., adult sisters/brothers, parent and adult child, college roommates,
etc.) all legally responsible adults must sign authorization.
c. Witness: The signing by the applicant and the owner/agent must be witnessed by someone unrelated to either party.

FEMA Form 010-0-10 (5/15)

REPLACES ALL PREVIOUS EDITIONS. (This form was consolidated with FF90-41)

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