Form FEMA Form 009-0-13 FEMA Form 009-0-13 Unit Pad Requirements – Information Checklist

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control Number 1660-NW90
Expiration: MM/DD/YYYY

UNIT PAD REQUIREMENTS - INFORMATION CHECKLIST

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-NEW). Please do not send your completed form 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 advising FEMA Individual Assistance applicants of the
requirements to occupy temporary housing units, of the requirements for final sales of the unit if FEMA offers a sale program for its temporary
housing units 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 the requested disaster-related temporary housing assistance.
Site Address: (Street, City, State, Zip code, Temp. Housing Unit Pad
Number(s). Attach map and detailed directions if rural route).

Property Manager Contact Information:

Additional Description of Pad Premises:
Number of Available Pads

Pad Type

Accessible Pads

Pad Size:
3 BDR

3 BDR Accessible

2 BDR

2 BDR Accessible

1 BDR

1 BDR Accessible

Pets Allowed

Utilities

Background Check Required

Rent Amount

Amps

Credit Check Required

Split Lot

School Bus Routes

Other

Wrap Around Services

Accessible Mailboxes

Accessible egress (pathway to unit)

Accessible Dumpsters

1 BDR Accessible

Within reasonable commuting distance
FEMA FORM 009-0-137 (05/14)

REPLACES FEMA Form 90-96

Accessible Playground area (and path)
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Requirements:

Yes

No

Unknown

Does your facility have the ability to provide and maintain all water, sanitary sewage, electrical, other
utilities connections provided on the site at the time of execution of the lease?
Will the facility have the ability to maintain the Pad and premises in good repair during the term of the
lease?
The Property Manager shall not discriminate against any of the Lessee's tenants or prospective
tenants on the basis of race, color, religion, nationality, sex, age, disability, English proficiency, or
economic status.

Certify:
I certify that this information is true and correct and understand that this document in no way guarantees a lease with FEMA until approved and
authorized by the contracting officer.
Name of Firm

Signature and Title

Date

Name of FEMA Representative

Signature

Date

FEMA FORM 009-0-137 (05/14)

REPLACES FEMA Form 90-96

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