Form FEMA Form 009-0-91 FEMA Form 009-0-91 Project Worksheet

O.M.B. NO. 1660-0017
Expires July 31, 2016

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
PROJECT WORKSHEET

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1.30 hours per response. The burden estimates includes time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. 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 (1660-0017). NOTE: Do not send your completed questionnaire to this address.
DISASTER
FEMA -

PROJECT #

PA ID #

DATE

CATEGORY

-DRWORK COMPLETE AS OF

DAMAGED FACILITY

:
APPLICANT

%

COUNTY

LOCATION

LATITUDE

LONGITUDE

DAMAGE DESCRIPTION AND DIMENSIONS

SCOPE OF WORK

Does the Scope of Work change the pre-disaster conditions at the site?
Special Considerations issues included?
Is there insurance coverage on this facility?
ITEM

CODE

YES
YES
NARRATIVE

NO
NO

YES

NO

Hazard Mitigation proposal included?
PROJECT COST
QUANTITY/UNIT

UNIT PRICE

TOTAL COST
PREPARED BY

TITLE

SIGNATURE

APPLICANT REP.

TITLE

SIGNATURE

FEMA FORM 009-0-91

PREVIOUS EDITION OBSOLETE

YES

NO

COST