Form FEMA Form 010-0-9 FEMA Form 010-0-9 Request for the Site Inspection

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
REQUEST FOR THE SITE INSPECTION

OMB Control Number:. 1660-0030
Expires 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

SITE CONTROL No. (As Assigned)

REGISTRATION No.

SITE INFORMATION

APPLICANT INFORMATION

SITE ADDRESS (House No. & Street Name)

CITY AND STATE

NAME (Last, First, Middle Initial)

CURRENT ADDRESS (House No. & Street Name)

COUNTY

NAME OF LANDOWNER

CITY AND STATE (Include Zip Code)

ADDRESS OF LANDOWNER

APPLICANT PHONE NO.
Primary:

LANDOWNER'S PHONE NO.

SITE TYPE

Primary:

EGSS

Group

Alternate:

Private

Commercial

Alternate:
TEMPORARY HOUSING
UNITS REQUIRED (Check
One)
1

2

TYPE OF UNIT

3

MH

TT

PM

UFAS

SITE UTILITY INFORMATION (Completed by THP contact through inquiry to applicant)
UTILITY AND TYPE

COMPANY NAME

ELECTRIC
GAS

RAMP
ADA/UFAS Compliant Unit
None

IS APPLICATION ON
OXYGEN?

Public
Well

SEWER

FAMILY COMPOSITION
ADULT
MALE

FEMALE

Natural
LP

WATER

SPECIAL NEEDS

None

YES

Public
Septic

FEMA Form 010-0-9 (4/15)

CHILD
MALE

FEMALE

NO

None

REPLACES FEMA Form 90-1

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
REQUEST FOR THE SITE INSPECTION
LANDOWNER AVAILABLE TO
ACCOMPANY INSPECTOR TO SITE
YES

DATE

APPLICANT SIGNATURE

NO

SITE DESCRIPTION AND DIRECTIONS (Form DFO to Site- attach map if necessary)

DRAFT
NAME OF SITE INSPECTOR (Assigned by DHOP's Chief)

DATE ASSIGNED

INSPECTION APPOINTMENT
DATE

FLOODPLAIN-VELOCITY ZONE DETERMINATION
Within

Outside Restricted Zone

TIME

1st Choice
2nd Choice

Flood Zone Map No.

APPLICANT ACTIONS TO MAKE SITE ACCEPTABLE

Site Feasible

Site Infeasible (State
reason)

SIGNATURE OF SITE INSPECTOR

FF 010-0-10 Landowner's Authorization/Ingress-Egress
Agreement
DATE

APPLICANT NOTIFIED OF SITE DETERMINATION
Date:

FEMA Form 010-0-9 (4/15)

REPLACES FEMA Form 90-1

FF 90-96, Mobile Lease

By:

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