Form FEMA Form 009-0-12 FEMA Form 009-0-12 PNP Facility Questionaire

DEPARTMENT OF HOMELAND SECURITY

O.M.B. Control Number: 1660-0017
Expires: December 31, 2019

Federal Emergency Management Agency
PNP FACILITY QUESTIONNAIRE

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average .5 hours per response. 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 not required
to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right
corner of 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, Paperwork Reduction
Project (1660-0017) NOTE: Do not send your completed form to this address.
FEMA and State personnel will use this questionnaire to determine the eligibility of specific facilities of an approved Private Non-Profit (PNP) organization (See 44
CFR 206.221). Owners of critical facilities (i.e., power, water (including providing by an irrigation organization or facility, if it is not provided solely for irrigation
purposes), sewer, wastewater treatment, communications and emergency medical care) can apply directly to FEMA for assistance for emergency work (debris
removal and emergency protective measures) and permanent work (repair, restore or replace a damaged facility). Owners of non-critical facilities can apply
directly to FEMA for assistance for emergency work, but must first apply to the U. S. Small Business Administration (SBA) for assistance for permanent work. If
the owner of a non-critical facility does not qualify for an SBA loan or the cost to repair the damaged facility exceeds the SBA loan amount, the owner may apply
to FEMA for assistance.
1. Name of PNP Organization

2. Name of the damaged facility and location

3. What was the primary purpose of the damaged facility
Yes

No

7. Was the facility in use at the time of the disaster?

Yes

No

8. Did the facility sustain damage as a direct result of the disaster?

Yes

No

Yes

No

4. Is the facility a critical facility as described above?
5. Who may use the facility
6. What fee, if any, is charged for the use of the facility

9. What type of assistance is being requested?
10. Does the PNP organization own the facility?
11. If "Yes" obtain proof of ownership; check here if attached.
Yes

12. Does the PNP organization have the legal responsibility to repair the facility?
13. If "Yes", provide proof of legal responsibility; check here if attached.

Yes

No

14. Is the facility insured?

Yes

No

No

15. If "Yes", obtain a copy of the insurance policy; check here if attached.
Additional information or comments:

Contact Person

FEMA FORM 009-0-121

Date

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