FEMA Form FF-104-F Project Application for Debris Removal
Public Assistance Program
FF-104-FY-22-239_Project Application for Debris Removal_Final
OMB: 1660-0017
D
EPARTMENT
OF HOMELAND SECURITY OMB
Control Number FF-104-FY-22-239
Federal Emergency Management Agency Expires Month Day, Year
PROJECT APPLICATION FOR DEBRIS REMOVAL |
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Paperwork Burden Disclosure Notice Public reporting burden for this data collection is estimated to average 45 minutes 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 required to obtain or retain benefits. You are not required to respond to this collection of this 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. |
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Privacy Act Statement The collection of this information is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 402-403, 406-407, 417, 423, 427, 428, 502, and 705; 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e, 5189f, 5192, 5205; Title 44 Code of Federal Regulations (C.F.R.) § 206 Subpart G; and 2 C.F.R. § 200. This information is collected to provide assistance to eligible jurisdictions and organizations to facilitate the response to and recovery from a Presidentially-declared disaster or emergency, or to provide assistance for hazard mitigation measures during the recovery process. The disclosure of information on this form is voluntary; however, failure to provide the requested information may delay or prevent the agency from receiving funds from FEMA’s Public Assistance program. |
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Purpose and Applicability Debris removal includes activities that eliminate immediate threats to lives, public health, and safety; eliminate immediate threats of significant damage to improved public or private property; and ensure economic recovery of the affected community to the benefit of the community at large by clearance, removal, and disposal when in the public interest. FEMA uses this form to collect information necessary to support the Applicant’s claim. To see all information and documentation that may be requested to substantiate work or costs or for more information, please see Chapter 7 Emergency Work Eligibility in the Public Assistance Program and Policy Guide and the Public Assistance Resource Library. Please contact the State, local, Tribal, or Territorial emergency management office for additional information.Recipients and Applicants should use Public Assistance Grants Portal to submit all documentation and information to FEMA. Questions are displayed in an intuitive manner to show the information and documentation needed based on answers provided. All signatures are official and legally binding. The following information is needed to complete this form:
Resources:
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Section I – Impact Groups and Project Information |
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Impact Groups |
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Based on previously provided information, the identified impact(s) have been grouped into a project.1 [List is system generated] |
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Do the grouped impact(s) need to be modified?2 ☐ No ☐ Yes.3 Please provide a reason for modifying grouped impacts: |
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What is the total amount associated with the newly grouped impact(s)?4 Applicant will be prompted to complete Small Project Information or Large Project Information based upon answers provided. [system generated] |
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Declaration & Applicant Information5 |
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Declaration # [system generated] |
Legal Name of Applicant: [system generated] |
FEMA PA ID: [system generated] |
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Project Information6 |
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Project #7 [system generated] |
Applicant-Assigned Project #8 (Optional) |
Project Title |
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Project Amendment #9 [system generated] |
Period of Performance deadline:10 [system generated] |
Work Type: Debris Removal |
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Impact line item(s) final grouping [system generated] |
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Is the Applicant requesting expedited funding?11 [system generated] Please update if changed. ☐ No ☐ Yes.12 Please describe immediate need for funding: |
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Do you want to make this impact a High Priority? High Priority means that FEMA will work with you to address this impact before any others you list.13 [system generated] Please update if changed. ☐ No ☐ Yes |
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(Optional) Please select the time-period for the activities being claimed on this project application: 14 Start Date: (MM/DD/YYYY) Designated Time-Period: ☐ 30 days ☐ 60 days ☐ 90 days ☐ Another time-period: |
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Section II – Expedited Project |
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Cost Estimate |
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Please upload an itemized cost estimate for this project. Please include the number and type of resources necessary to complete the work.
What is the basis for the estimate? ☐ Actual costs ☐ Historical unit costs ☐ Average costs for similar work in the area ☐ Contractor or vendor quotes ☐ Other.15 Please describe:
What resources did [will] the Applicant use to complete the work? Please select all that apply. ☐ Contracted Has the Applicant procured and selected a contractor? ☐ No ☐ Yes How did the Applicant ensure the contract costs were reasonable? ☐ Competitive procurement process ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Other.16 Please describe:
What is the total cost of contracted work?
☐ Labor ☐ Applicant’s own employees What is the total cost of employee labor?
☐ Mutual aid, prison labor, or national guard What is the total cost of mutual aid, prison labor, or national guard?
☐ Equipment ☐ Applicant’s own equipment ☐ Purchased or rented equipment Has the Applicant completed the purchase or rental? ☐ No ☐ Yes How did the Applicant ensure the costs were reasonable? ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Obtained multiple quotes ☐ Other. Please describe:
What is the total cost of equipment?
☐ Materials ☐ From Stock ☐ Purchased Has the Applicant completed the purchase? ☐ No ☐ Yes How did the Applicant ensure the costs were reasonable? ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Obtained multiple quotes ☐ Other. Please describe:
What is the total cost of materials?
☐ Donated Resources ☐ Labor ☐ Equipment ☐ Materials ☐ Buildings or Land ☐ Permanent17 ☐ Temporary18 ☐ Space ☐ Logistical Support
What is the total value?
☐ Additional Debris Removal costs ☐ Travel ☐ Meals ☐ Miscellaneous. Please describe:
What is the total additional debris removal costs?
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Section III – Small Project20 This option is only available for projects totaling up to the large project threshold. |
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Description of Activities |
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☐ Navigable. Did [Does] the debris obstruct the passage of vessels? ☐ No ☐ Yes ☐ Non-navigable. Please describe how the debris did [does] pose an immediate threat? 22
Please provide an estimated number of removed stumps, trees, limbs, or branches or upload documentation containing the same level of information: 24
Please describe any efforts undertaken to contact the owners of abandoned vehicles and vessels, and efforts made to track and document handling of vehicles and vessels:
What is the total quantity of debris removed? Quantity: . Units: ☐ Cubic Yards, ☐ Tons, or ☐ Each ☐ Actual Quantity ☐ Estimated Quantity Which of the following are being used to manage debris? Please select all that apply.
Site Name: Site Location: (Address or GPS) Was the site authorized for debris staging by a state or local regulatory agency?
☐ No Please describe how the debris will be hauled, the site surface and any work done or planned to restore the site back to its pre-disaster use: ☐ Final disposal site(s) Site Name: Site Location: (Address or GPS) Was the site authorized for debris staging by a state or local regulatory agency?
☐ No Please describe how the debris will be loaded and hauled to the final disposal site: Please describe how debris will be disposed at the final site (e.g., burying, dumpster, landfill, recycled): ☐ Will debris be reduced on site? ☐ No ☐ Yes. Quantity reduced: Units: Cubic Yards, Tons, or Each Please describe the reduction method (e.g., chipping or grinding, compaction, open burning):
If any debris activities are planned for private property, please describe the activities, including the Applicant’s legal responsibility and authority to enter private property, and the basis for the determination that a threat exists to the general public: 27 |
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General Cost and Work Status Information |
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Has the Applicant started any of the work activities claimed on this project application? [system generated] ☐ All work is complete Please provide work start and end dates (MM/DD/YYYY) - (MM/DD/YYYY). ☐ Work has started and is approximately % complete. Please provide the start date and a projected end date, if known: (MM/DD/YYYY) - (MM/DD/YYYY) ☐ Work has not started. Please provide a projected start date: (MM/DD/YYYY) Does the Applicant have insurance for this work? [system generated] ☐ No, the facilities and work were not insured.28 ☐ Yes, the Applicant anticipates receiving $ . ☐ Yes, the Applicant received $ . ☐ Yes, but the Applicant is uncertain of the amount it will receive.29 ☐ Yes, but the insurance company denied the claim. Please provide an explanation of denied claim or upload denial correspondence.30 Has [Does] the Applicant received [anticipate receiving] funding from another source for this work? 31 Please update if changed. [system generated] ☐ No ☐ Yes. Please check all that apply: ☐ Cash Donations. Please describe: Amount $ ☐ Federal Grants.32 Please describe: Amount $ ☐ Non-Federal Grants. Please describe: Amount $ ☐ Revenue. Please describe: Amount $ ☐ Third-Party Liability.33 Please describe: Amount $
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Cost Estimate |
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Please upload an itemized cost estimate for this project. Please include the number and type of resources necessary to complete the work.
What is the basis for the estimate? ☐ Actual costs ☐ Historical unit costs ☐ Average costs for similar work in the area ☐ Contractor or vendor quotes ☐ Other.34 Please describe:
What resources did [will] the Applicant use to complete the work? Please select all that apply. ☐ Contracted Has the Applicant procured and selected a contractor? ☐ No ☐ Yes How did the Applicant ensure the contract costs were reasonable? ☐ Competitive procurement process ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Other. Please describe:
What is the total cost of contracted work?
☐ Labor ☐ Applicant’s own employees What is the total cost of employee labor?
☐ Mutual aid, prison labor, or national guard What is the total cost of mutual aid, prison labor, or national guard?
☐ Equipment ☐ Applicant’s own equipment ☐ Purchased or rented equipment Has the Applicant completed the purchase or rental? ☐ No ☐ Yes How did the Applicant ensure the costs were reasonable? ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Obtained multiple quotes ☐ Other. Please describe:
What is the total cost of equipment?
☐ Materials ☐ From Stock ☐ Purchased Has the Applicant completed the purchase? ☐ No ☐ Yes How did the Applicant ensure the costs were reasonable? ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Obtained multiple quotes ☐ Other. Please describe:
What is the total cost of materials?
☐ Donated Resources ☐ Labor ☐ Equipment ☐ Materials ☐ Buildings or Land ☐Permanent ☐Temporary ☐ Space ☐ Logistical Support
What is the total value?
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☐ Additional Debris Removal costs ☐ Travel ☐ Meals ☐ Miscellaneous. Please describe:
What is the total additional debris removal costs?
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Section IV – Small Project Closeout Request35 |
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Has the Applicant completed all the work associated with the project? ☐ No ☐ Yes. Work Completed date: (MM/DD/YYYY)36 Does the Applicant want to close this project or other small projects as well? 37 ☐ Applicant wants to closeout this project only. ☐ Applicant wants to closeout multiple small projects.38 ☐ Applicant wants to closeout all small projects.39
The Applicant may request additional funding if its combined actual cost of all its Small Projects exceeded the combined cost FEMA approved for all its Small Projects. Does the Applicant wish to claim any costs that exceeded the total amount obligated?40 [system generated for the small project with the latest period of performance] ☐ No ☐ Yes. Please upload all documentation to support work and costs for all small projects. |
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Total approved amount [system generated] |
Federal share obligated [system generated] |
Date obligated [system generated |
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Section V – Large Project41 |
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Description of Activities |
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☐ Navigable Did [Does] the debris obstruct the passage of vessels? ☐ No43 ☐ Yes44 ☐ Non-navigable. Please describe how the debris did [does] pose an immediate threat? 45 How did [does] the debris pose an immediate threat? ☐ Debris obstructs, or could obstruct, intake structures. ☐ Debris is causing, or could cause damage to structures, such as bridges and culverts. ☐ Debris is causing, or could cause, flooding to improved public or private property during the occurrence of a five-year flood. ☐ Other threat. Please describe: Was [will] any debris [be] removed from streams? ☐ No ☐ Yes46 Has the Applicant requested assistance from the Natural Resources Conservation Service? ☐ No.47 ☐ Yes. Please upload related correspondence.48 Was [will] any debris [be] removed from flood control works? 49 ☐ No ☐ Yes Is the flood control work part of the Watershed and Flood Prevention Operations Program under PL 83-566? ☐ No ☐ Yes50
Please select the type of debris removed:
☐ Stump How was [will] the stump [be] removed? ☐ Extracting ☐ Flush cut ☐ Grinding What percent of root-ball was [is] exposed? ☐ 50% or more54 ☐ Less than 50% Did [will] the Applicant remove a root-ball? ☐ No ☐ Yes ☐ Tree that extends over improved property or public-use area ☐ Split trunk ☐ Broken canopy ☐ Leaning at an angle greater than 30 degrees ☐ Broken limb or branch that extends over improved property or public-use area
Please describe any efforts undertaken to contact the owners of abandoned vehicles and vessels, and efforts made to track and document handling of vehicles and vessels:
Did [will] the vehicles [vessels] need to be stored prior to identifying the owners? ☐ No ☐ Yes56 ☐ Other
Please provide the original location of the debris: 57 Please upload a representative sample of debris photographs. [system generated] Please update if needed. ☐ Throughout jurisdiction ☐ Specific areas. Please describe (e.g., specific neighborhood, quadrant, etc.): ☐ Specific address or GPS coordinates: Which of the following are being used to manage debris? Please select all that apply.
Site Name: Site Location: Address or GPS
Was [will] contract labor [be] used to manage the site? ☐ No ☐ Yes What type of labor was [will be] used for debris monitoring at the site? Please select all that apply. ☐ Applicant employees ☐ Contract. Please provide name:
Was the site authorized for debris staging by a state or local regulatory agency? ☐ No
How was [will] the debris [be] loaded and hauled? ☐ Trucks with solid tailgate ☐ Trucks without solid tailgate ☐ Hand-loaded ☐ Barge/Other. Please describe:
Quantity [to be] hauled59 ☐ Actual ☐ Estimate ☐ Cubic yards ☐ Tons ☐ Each
Number of load tickets60 ☐ Fewer than 45. Please upload all load tickets. ☐ 45 or more. Please upload either a random sample of 45 load tickets or a list of all load tickets.
Haul price per unit61 $/Cubic yard $/Ton $/Each
Total haul cost: $[system calculated]62
Was [will] the debris [be] reduced on site?63 ☐ No ☐ Yes. Quantity reduced: Units: Cubic Yards, Tons, or Each Please select the reduction method: ☐ Air curtain burning.64 Please upload a copy of the permit. ☐ Chipping or grinding ☐ Compacting ☐ Open burning. Please upload a copy of the permit. ☐ Other. Please describe:
Reduction price per unit ☐ $/Cubic yard ☐ $/Ton ☐ $/Each
Total reduction cost: $[system calculated] 65
☐ Final disposal site(s) Site Name: Site Location: (Address or GPS)
Was the site authorized for debris staging by a state or local regulatory agency? ☐ No
Was [will] contract labor [be] used to load/haul debris to this site? ☐ No ☐ Yes What type of labor was [will be] used for debris monitoring at the site? Please select all that apply. ☐ Applicant employees ☐ Contract. Please provide name:
How was [will] the debris [be] loaded and hauled? ☐ Trucks with solid tailgate ☐ Trucks without solid tailgate ☐ Hand-loaded ☐ Barge/Other. Please describe:
Quantity [to be] hauled ☐ Actual ☐ Estimate ☐ Cubic yards ☐ Tons ☐ Each
Number of load tickets66 ☐ Fewer than 45. Please upload all load tickets. ☐ 45 or more. Please upload either a random sample of 45 load tickets or a list of all load tickets.
Haul price per unit67 $/Cubic yard $/Ton $/Each
Total haul cost: $[system calculated] 68
Was [will] the debris [be] reduced on site?69 ☐ No ☐ Yes. Quantity reduced: Units: Cubic Yards, Tons, or Each Please select the reduction method: ☐ Air curtain burning. Please upload a copy of the permit. ☐ Chipping or grinding ☐ Compacting ☐ Open burning. Please upload a copy of the permit. ☐ Other. Please describe:
Reduction price per unit $/Cubic yard $/Ton $/Each
Total reduction cost: $[system calculated] 70
Please select the disposal method: ☐ Burying ☐ Composted ☐ Dumpster ☐ Landfill ☐ Recycled ☐ Spreading ☐ Supplied to public/Made available for reuse ☐ Other. Please describe:
Tipping fee per unit $/Cubic yard $/Ton $/Each
Total disposal cost $[system calculated] 71 |
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General Cost and Work Status Information |
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Has the Applicant started any of the work activities claimed on this project application?72 [system generated] Please update if changed. ☐ All work is complete.73 Please provide work start and end dates (MM/DD/YYYY) - (MM/DD/YYYY). ☐ Work has started and is approximately % complete. Please provide the start date and a projected end date, if known: (MM/DD/YYYY) - (MM/DD/YYYY) ☐ Work has not started. Please provide a projected start date: (MM/DD/YYYY) |
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Please indicate what type of cost was used for this project: Please select all that apply: ☐ Actual cost. Please complete actual cost table below. ☐ Estimate for future cost. ☐ Estimated contracted cost: $ ☐ Estimated labor cost: $ ☐ Estimated equipment cost: $ ☐ Estimated materials cost: $ ☐ Estimated other costs: $ |
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☐ No, the facilities and work were not insured.75 ☐ Yes, the Applicant anticipates receiving $ . ☐ Yes, the Applicant received $ . ☐ Yes, but the Applicant is uncertain of the amount it will receive.76 ☐ Yes, but the insurance company denied the claim. Please upload denial correspondence.77
☐ Third-Party Liability. Please describe: Amount $ |
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Actual Cost Information |
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Impact Line Item: 79 Please select one. [system generated list of impacts]
What resources did the Applicant use to complete the work? Please select all that apply. ☐ Contracted ☐ Labor ☐ Equipment ☐ Materials ☐ Additional debris removal costs80 |
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Contracted Costs |
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Please complete the Contract Information form for all contracts that have an estimated value of more than $1,000,000. Has the Applicant procured and selected a contractor? 81 ☐ No ☐ Yes.82 How did the Applicant ensure the contract costs were reasonable? Please upload a copy of the awarded contract, bid package, any change orders, and invoices. ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Obtained multiple quotes ☐ Other. 83 Please describe: |
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Labor and Equipment |
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Name of Individual 84 ☐ Donated labor85 ☐ Applicant employee ☐ Mutual aid86 ☐ Emergency Management Assistance Compact (EMAC). Please upload the following documents:
☐ Other: |
Rate type87 [Optional if only claiming Equipment] ☐ Straight time $ ☐ Overtime $ ☐ Premium $ ☐ Hazard $ |
Date(s) 88
Hours
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Total hours: 89 [system calculated] Labor hours: [system calculated] Equipment hours: [system calculated]
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Total Cost 90 [system calculated] Labor cost $ [system calculated] Equipment cost $ [system calculated] Donated value $ [system calculated]
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Equipment Description and source91 ☐ Applicant owned ☐ Purchased92 ☐ Rented93 ☐ Donated |
Is the Applicant claiming mileage or hourly rate? 94 ☐ Mileage ☐ Equipment $ |
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How did the Applicant ensure the costs were reasonable? 95 ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Obtained multiple quotes ☐ Other.96 Please describe: |
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Materials97 |
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Material description
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How was the material obtained? 98 ☐ Donated 99 ☐ Purchased ☐ From Stock |
Purchased Date (MM/DD/YYYY) |
Used Date (MM/DD/YYYY) |
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Quantity Purchased
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Unit Price
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Quantity Used
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Fair Market Value100
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Total Cost101 Donated value $ 102 [system calculated] Total cost $ [system calculated] |
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How did the Applicant ensure the costs were reasonable? 103 ☐ Cost or price analysis ☐ Compared to historical costs for similar projects in the area ☐ Obtained multiple quotes ☐ Other. Please describe: |
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Additional debris removal costs104 |
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Description ☐ Travel ☐ Meals 105 ☐ Miscellaneous. Please describe: ☐ Donated ☐ Permanent ☐ Temporary |
Vendor/Donor106
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Purchased/Donated Date |
Used Date
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Quantity Purchased/ Donated
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Fair Market Value
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Total Cost107 [system calculated] |
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Section VI – Scope of Work and Cost Summary |
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Work Summary |
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Scope of Work: [system generated] |
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Closeout Project Scope of Work: [system generated] |
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Cost breakdown108 |
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Estimated Costs |
Closeout Final Costs |
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[system calculated below] Contract:
Labor ☐ Applicant’s own employees: ☐ Mutual Aid:
Equipment: ☐ Applicant’s own equipment: ☐ Purchased equipment: ☐ Rented equipment:
Materials: ☐ Stock materials: ☐ Purchased materials:
Additional debris removal costs ☐ Travel ☐ Meals 109 ☐ Miscellaneous |
[system calculated below] Contract:
Labor ☐ Applicant’s own employees: ☐ Mutual Aid:
Equipment: ☐ Applicant’s own equipment: ☐ Purchased equipment: ☐ Rented equipment:
Materials: ☐ Stock materials: ☐ Purchased materials:
Additional debris removal costs ☐ Travel ☐ Meals ☐ Miscellaneous |
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Deductions: ☐ Insurance: ☐ Other sources: |
Deductions: ☐ Insurance: ☐ Other sources: |
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Donated Resources: 110 ☐ Labor: ☐ Equipment: ☐ Material: ☐ Buildings or Land: ☐ Space: ☐ Logistical Support: |
Donated Resources: ☐ Labor: ☐ Equipment: ☐ Material: ☐ Buildings or Land: ☐ Space: ☐ Logistical Support: |
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Grand total: |
Grand total: |
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Section VII – Additional Information and Comments [Optional] If you have any additional information and supporting documentation not previously provided, use this section to help support your claim. Please ensure personally identifiable information is redacted on any documentation submitted.111 |
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Please provide any additional information, comments, or a brief description of the uploaded documentation, if applicable: |
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Section VIII – Applicant Project Acknowledgements and Certifications |
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I acknowledge and certify that I have reviewed and understand the following information regarding overarching requirements to receive Public Assistance. Please initial next to each statement. The requirement to comply with applicable Federal, State, local, Tribal, and Territorial laws, regulations, and executive orders. Non-compliance may result in denial or deobligation of funding. This includes but is not limited to laws prohibiting discrimination; complying with the most restrictive of its own documented policies and procedures used for procurements with non-Federal funds; Federal procurement and contracting laws in accordance with 2 C.F.R. §§ 200, compliance with the Environmental Protection Agency guidelines for procurement of recovered materials; environmental and historic preservation laws; and inclusion of required provisions as applicable. Applicants must maintain all source documentation for each Project for 3 years after the date of transmission of the Closeout Form as certified by the Recipient. Recipients must keep all financial and program documentation for 3 years after the date it submits the final SF-425, in accordance with Title 2 C.F.R. §200.334-337. Longer retention periods may apply to real property and equipment disposition, audits, and litigation. Additionally, State, local, Tribal, or Territorial government laws may require longer retention periods. The requirement to inform FEMA of all purchased equipment with a fair market value over $5,000 after it is no longer needed for federally funded programs or projects in accordance with 2 C.F.R. § 200.313. FEMA reduces eligible funding by this amount. The requirement to inform FEMA if the aggregate fair market value of unused supplies purchased for FEMA projects is over $5,000 after they are no longer needed for federally funded programs or projects in accordance with 2 C.F.R. § 200.314. FEMA reduces eligible funding by this amount. All activities on private property must have completed all necessary legal processes and obtained rights-of-entry and agreements to indemnify and hold harmless the Federal Government. |
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As required by Title VI of the Civil Rights Act of 1964, Sections 308 and 309 of the Stafford Act, and applicable provisions of laws and authorities prohibiting discrimination, all work claimed was [will be] delivered in an impartial and equitable manner. As required by 44 C.F.R. § 206.228 and 2 C.F.R. Part 200.404, the costs claimed were of a type generally recognized as ordinary and necessary for the type of facility and work. As required by Stafford Act § 312, I certify that I am not claiming any work or costs that are covered by another source such as revenue, non-federal grants, cash donations, another Federal agency, or another FEMA Program (e.g., Individual Assistance programs or Hazard Mitigation Grant Program). If I receive funding for any work or costs in this project application, I will notify the Recipient and FEMA, and funding will be reconciled to eliminate duplication. All information provided regarding the project application is true and correct to the best of my knowledge. Upon submittal this project application becomes a legal document. The Recipient or FEMA may use external sources to verify the accuracy of the information entered. It is a violation of Federal law to intentionally make false statements or hide information when applying for Public Assistance. The False Claims Act (31 U.S.C. §§3729-3733) prohibits the submission of false or fraudulent claims for payment to the federal government. Suspicion of fraudulent activities should be reported to the FEMA Disaster Fraud Hotline, the Department of Homeland Security's Office of the Inspector General, or the Department of Justice Fraud Hotline. I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain Public Assistance, it is a violation of Federal laws, which carry severe criminal and civil penalties including a fine of up to $250,000, imprisonment, or both. (18 U.S.C. §§ 287, 1001, 1040, and 3571). |
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Applicant Signature |
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Applicant Authorized Representative [system generated] |
Title [system generated] |
Signature [system generated] |
Date submitted112 [system automated] |
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Section IX – Recipient Recommendation113 |
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Does all work in this project meet the criteria to be an eligible for Public Assistance funding? ☐ No. Please describe why: ☐ Yes |
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Recipient Authorized Representative [system generated] |
Title [system generated] |
Signature [system generated] |
Date submitted114 [system automated] |
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Section X – Large Project Closeout Request115 |
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Has the Applicant completed all the work associated with the project? ☐ No ☐ Yes.116 Proceed to the General Cost and Work Status Information section to provide the final costs and upload supporting documentation. |
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Work Completed date (MM/DD/YYYY) 117 [system generated] Please update if changed. |
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Total approved amount [system generated] |
Federal share obligated [system generated] |
Date obligated [system generated] |
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Section XI – Applicant Closeout Acknowledgements and Certifications |
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I acknowledge and certify that I have reviewed and understand the following information regarding overarching requirements to receive Public Assistance. Please initial next to each statement. Projects were completed in accordance with 44 C.F.R. § 206.205 and the FEMA approved scopes of work, all necessary documents have been received, and any appeal for project overruns have been reconciled.
The Stafford Act Section 705 imposes a 3-year limit on FEMA’s authority to recover payments made to non-federal government Recipients and Subrecipients unless there is evidence of fraud. Section 705 does not apply to Private Non-profit organizations. I have read and understand FEMA issued Recovery Policy (FP 205-081-2), Stafford Act Section 705, Disaster Grant Closeout Procedures, which describes the limitations and requirements in detail. |
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Applicant Authorized Representative [system generated] |
Title [system generated] |
Signature [system generated] |
Date submitted118 [system automated] |
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Section XII – Recipient Closeout Acknowledgements and Certifications |
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I certify that I have reviewed and understand the following information regarding overarching requirements to receive Public Assistance. Please initial next to each statement. I certify that all costs were incurred in the performance of eligible work, that the projects were completed in accordance with the FEMA approved scopes of work, and that the project is in compliance with the provisions of the FEMA-State/Tribe/Territory Agreement in accordance with 44 C.F.R. § 206.205.
I certify that the Recipient paid its applicable contribution to the non-Federal share, in accordance with the FEMA-State/Tribe/Territory Agreement. |
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Recipient Authorized Representative [system generated] |
Title [system generated] |
Signature [system generated] |
Date submitted119 [system automated] |
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1 Functionality: Generate default groupings based on the line items selected on the Impact List Addendum. Display all impacts within each group.
2 Functionality: Allow Applicant and/or PDTFL to modify groupings.
3 Functionality: A reason for modifying grouped impacts required. Notify PDTFL to evaluate whether the reason aligns with PAPPG logical grouping. Display all impacts based on selections in the Impact List Addendum and allow each impact to be re-grouped. Do not allow line items marked as “all work is complete” to be combined with line items that are not complete.
4 Functionality: Calculate amount based on new impacts groups and populate correct option below.
5 Functionality: Generate Declaration #, Legal Name of Applicant, and PAID from the RPA.
6 Functionality: Generate Declaration # from the Incident Information. Generate Legal Name of Applicant and FEMA PA ID from the Organization Profile.
7 Functionality: Assign a Project number.
8 (Help text) The Applicant may assign a unique number to each Project Application for internal tracking purposes. Functionality: Optional, not required.
9 Functionality: Assign a Project Amendment number.
10 Functionality: Automate based on standard period of performance deadlines by category and any approved time extensions.
11 (Help text) Requests for Expedited Projects must be submitted to FEMA within 60 days of the Applicant’s Recovery Scoping Meeting or Recovery Scoping Video. Functionality: Only ask if the total estimated cost for the activities is equal to or more than the Small Project Maximum threshold. Do not ask after 60 days from the Applicant's Recovery Scoping Meeting or Recovery Scoping Video.
12 (Help Text) If approved, the Applicant will only receive 50% of the FEMA-confirmed project cost. The Applicant must provide all information to support the initial 50%, including documentation to support actual costs, before receiving additional funds.
13 Functionality: Generate from “Do you want to make this impact a high priority?” in the Impact List. Show the highest priority level of all selected impacts (i.e., if some are “high” and some are “standard”, overall project says “high”).
14 (Help text) Because expedited funding is awarded based on reduced documentation requirements, FEMA funds these projects for specific time periods. Functionality: Required for Expedited Funding projects. Otherwise, the response is optional.
15 Functionality: Flag for Recipient and FEMA review of estimating methodology.
16 Functionality: Flag for Recipient and FEMA review of method used to determine costs to be reasonable.
17 (Help text) For buildings or land donated permanently (i.e., with a transfer of ownership), offset is based on the fair market value at the time of donation as established by an independent appraisal and certified by the Applicant.
18 (Help text) For building or land space donated for temporary use, the offset is based on the fair rental value of comparable privately-owned space in the same locality as established by an independent appraisal.
19 Functionality: Calculate based on the sum of the Total Costs minus the Total Funds.
20 Functionality: Trigger Small Project Information section if the total amount indicated in “Total anticipated amount” in the Impact List is below the Large Project Threshold. Functionality: Generate Environmental and Historical Preservation (EHP) Addendum if any EHP triggers were identified in the Impact List.
21 (Help text) Debris Removal includes hauling and disposing.
22 (Help text) Examples can include obstruction of intake structure, damage to structures (e.g., bridges and culverts), flooding to improved public or private property during the occurrence of a five-year flood.
23 (Help text) Eligible vegetative debris may include tree limbs, branches, stumps, or trees that are still in place, but damaged to the extent they pose an immediate threat. These items are ineligible if the hazard existed prior to the incident, or if the item is in a natural area and does not extend over improved property or public-use areas, such as trails, sidewalks, or playgrounds. See the Hazardous Limbs, Trees, and Stumps section in the PAPPG for more information.
24 (Help text) Stump and tree removal may trigger Environmental and Historical Preservation requirements related to ground disturbance. Please ensure to keep records of each removal location.
25 (Help text) The removal of a privately-owned vehicle or vessel from public property is eligible if it blocks access to a public-use area, is abandoned, and the Applicant follows applicable SLTT government ordinances and laws. The Applicant needs to retain documentation to support it met these criteria. See the Privately Owned Vehicles and Vessels on Public Property section in the PAPPG for more information. See NOAA’s Abandoned and Derelict Vessels Info Hub or salvaging solutions for more information.
26 (Help text) Temporary debris management sites provide a community with time and space to further segregate and process debris. Processing of debris may be necessary to reduce its volume or toxicity prior to treatment or disposal. Certain debris types may pose a risk to human health and the environment when accumulated, staged, or stored in large quantities at temporary debris management sites. For example, vegetative debris piles can spontaneously combust under the right conditions. Measures should be implemented that address these concerns. In addition, temporary debris management sites should not be located where they can damage cultural resources and historic properties (e.g., by the trucking in and placement of large amounts of debris). The State Historic Preservation Officer or Tribal Historic Preservation Officer should be notified to help ensure that these irreplaceable resources are not present or, if they are, remain protected from possible damage.
27 (Help text) FEMA’s approval is required for any debris removal activities conducted on private or commercial property. Please submit the Request for Approval- Private Property Debris Removal form. Functionality: Trigger if previous activity selection indicates work on private property. Trigger the Private Property Debris Removal Request for Approval form.
28 (Help text) If an applicant received Public Assistance funding on a previous event and was required to obtain and maintain insurance for a specific amount, failure to do so could jeopardize funding for the current event. Functionality: If "No, the facilities and work were not insured" is selected, notify PDMG and Insurance Specialist for review.
29 (Help text) FEMA may reduce the total estimated project cost by an estimated amount of insurance proceeds based on a review of the Applicant’s insurance policy.
30 Functionality: Documentation required prior to submission of the Project Application.
31 (Help text) FEMA is legally prohibited from duplicating benefits from other sources. If the Applicant receives funding from another source for the same work that FEMA funded, FEMA reduces the eligible cost or de-obligates funding to prevent a duplication of benefits. See Section 312 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act for more information.
32 (Help text) See the Non-Federal Grants and Cash Donations section in the PAPPG for more information.
34 Functionality: Flag for Recipient and FEMA review of estimating methodology.
35 Functionality: Only show this section if the work is 100% complete.
36 (Help text) 2 CFR § 200.344(a). The recipient must submit, no later than 120 calendar days after the end date of the period of performance, all financial, performance, and other reports as required by the terms and conditions of the Federal award. An Applicant must submit to the pass-through entity, no later than 90 calendar days (or an earlier date as agreed upon by the Recipient (pass-through entity) and Applicant) after the end date of the period of performance, all financial, performance, and other reports as required by the terms and conditions of the Federal award. The Federal awarding agency or pass-through entity may approve extensions when requested and justified by the Recipient (non-Federal entity), as applicable. Functionality: Generate date from General Cost and Work Status Information section if work is shown as complete.
37 Functionality: Generate Applicant and Recipient Closeout Acknowledgements and Certifications sections.
38 Functionality: Generate list of available small projects and allow the Applicant to select multiple small projects.
39 Functionality: Auto-select all small projects.
40 (Help text) Applicants may request additional funding within 60 days of the work completion on its last small project. Functionality: Generate this question if Applicant wants to close all small projects was selected.
41 Functionality: Trigger Large Project Information section if the total amount indicated in “Total anticipated amount for FEMA claim” in the Impact List is above the Small Project Maximum Threshold. Functionality: Generate Environmental and Historical Preservation (EHP) Addendum if any EHP triggers were identified in the Impact List.
42 (Help text) Debris Removal includes hauling and disposing.
43 (Help text) Any debris below this zone is ineligible unless it is necessary to remove debris extending upward into an eligible zone. See the Navigable Waterways section of the PAPPG for more information.
44 (Help text) Debris removal is only eligible up to a maximum depth of two feet below the low-tide draft of the largest vessel that utilized the waterway prior to the incident.
45 (Help text) Examples can include obstruction of intake structure, damage to structures (e.g., bridges and culverts), flooding to improved public or private property during the occurrence of a five-year flood.
46 (Help text) Debris removal from streams may be eligible under the Natural Resources Conservation Service’s (NRCS) Emergency Watershed Protection Program (EWPP).
47 (Help text) Removal of the obstruction is eligible in streams where debris removal might also be eligible under the NRCS EWPP unless NRCS provides assistance for the debris removal. However, the Applicant needs to coordinate with NRCS first to ensure that any work performed does not jeopardize other assistance that may be eligible under the EWPP.
48 Functionality: Required prior to submitting the Project Application.
49 (Help text) Flood control works are structures such as levees, flood walls, flood control channels, and water control structures designed and constructed to have appreciable effects in preventing damage by irregular and unusual rises in water levels.
50 (Help text) Debris removal from flood control works that are under the specific authority of NRCS is ineligible for Public Assistance funding, even if the National Resources Conservation Service does not have sufficient funding or does not provide assistance. Flood control works under the specific authority of the National Resources Conservation Service are those that are part of the Watershed and Flood Prevention Operations Program under PL 83-566.220.
51 (Help text) The C&D debris recycling industry has had several technological advances that make debris sorting and recycling more feasible. With prior planning and preparation, more efficient segregation of C&D debris is possible. More information about C&D debris recycling can be found on EPA’s website at https://www.epa.gov/smm/sustainable-management-construction-and-demolition-materials.
52 (Help text) EPA’s Responsible Appliance Disposal (RAD) partner programs help protect the ozone layer and reduce emissions of greenhouse gases by disposing of white goods (e.g., refrigerated appliances, such as refrigerators, freezers, window air-conditioning units, and dehumidifiers) using the best environmental practices and technologies available. Select the link to find responsible recyclers for electronics.
53 (Help text) Eligible vegetative debris may include tree limbs, branches, stumps, or trees that are still in place, but damaged to the extent they pose an immediate threat. These items are ineligible if the hazard existed prior to the incident, or if the item is in a natural area and does not extend over improved property or public-use areas, such as trails, sidewalks, or playgrounds. See the Hazardous Limbs, Trees, and Stumps section in the PAPPG for more information.
54 (Help text) For stumps or trees that have less than 50 percent of the root-ball exposed, FEMA only provides PA funding to flush cut the item at ground level and dispose of the cut portion. See the Hazardous Limbs, Trees, and Stumps section in the PAPPG for more information.
55 (Help text) The removal of a privately-owned vehicle or vessel from public property is eligible if it blocks access to a public-use area, is abandoned, and the Applicant follows applicable SLTT government ordinances and laws. The Applicant needs to retain documentation to support it met these criteria. See the Privately Owned Vehicles and Vessels on Public Property section in the PAPPG for more information. See NOAA’s Abandoned and Derelict Vessels Info Hub or salvaging solutions for more information.
56 (Help Text) If the owner is identified, the Applicant should work with private property owners to pursue and recover storage and removal costs and credit FEMA the Federal share of any funds received. See the Privately Owned Vehicles and Vessels on Public Property section of the PAPPG for more information.
57 Functionality: Generate from the Impact List.
58 (Help text) Temporary debris management sites provide a community with time and space to further segregate and process debris. Processing of debris may be necessary to reduce its volume or toxicity prior to treatment or disposal. Certain debris types may pose a risk to human health and the environment when accumulated, staged, or stored in large quantities at temporary debris management sites. For example, vegetative debris piles can spontaneously combust under the right conditions. Measures should be implemented that address these concerns. In addition, temporary debris management sites should not be located where they can damage cultural resources and historic properties (e.g., by the trucking in and placement of large amounts of debris). The State Historic Preservation Officer or Tribal Historic Preservation Officer should be notified to help ensure that these irreplaceable resources are not present or, if they are, remain protected from possible damage.
59 (Hep Text) If the Applicant selected trucks without a solid tailgate, the quantity will be reduced hauled by 15%. If the Applicant selects hand-loaded trucks and trailers, the quantity will be reduced by 50% Functionality: If Applicant selected trucks without a solid tailgate, reduce quantity hauled by 15%. If Applicant selected hand-loaded trucks and trailers, reduce quantity by 50%.
60 Functionality: Only request if contract labor was used to load/haul debris to this site.
61 Functionality: Only request if contract labor was used to load/haul debris to this site.
62 Functionality: Calculate based on quantity hauled x unit price.
63 Functionality: If “No” is selected, no other “Reduction Information” questions are asked.
64 (Help text) An air curtain burner places a high velocity curtain of air over a defined burn chamber, which can be a temporary pit in the ground or a well-conceived above ground structure with refractory walls.
65 Functionality: Calculate based on quantity reduced x reduction price per unit.
66 Functionality: Only request if contract labor was used to load/haul debris to this site.
67 Functionality: Only request if contract labor was used to load/haul debris to this site.
68 Functionality: Calculate based on quantity hauled x haul price per unit. If trucks “without solid tailgate” or “hand-loaded” selected, include the reduced percentage in the calculation.
69 Functionality: If “No” is selected, no other “Reduction Information” questions are asked.
70 Functionality: Calculate based on quantity reduced x reduction price per unit.
71 Functionality: Calculate based on quantity reduced x tipping fee per unit.
72 Functionality: The Applicant may update this section any time prior to submitting a project completion certification. If work is 100% complete upon submission, populate closeout section.
73 Functionality: Do not allow this activity to be combined with activities that do not have this box checked.
74 Functionality: If “Yes” is selected for any of the options and insurance policy has not already been provided, insurance policy is required prior to submitting the Project Application.
75 (Help text) If an applicant received Public Assistance funding on a previous event and was required to obtain and maintain insurance for a specific amount, failure to do so could jeopardize funding for the current event. Functionality: If "No, the facilities and work were not insured" is selected, notify PDMG and Insurance Specialist for review.
76 (Help text) FEMA may reduce the total estimated project cost by an estimated amount of insurance proceeds based on a review of the Applicant’s insurance policy.
77 Functionality: Documentation required prior to submission of the Project Application.
78 (Help text) FEMA is legally prohibited from duplicating benefits from other sources. If the Applicant receives funding from another source for the same work that FEMA funded, FEMA reduces the eligible cost or de-obligates funding to prevent a duplication of benefits. See Section 312 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act for more information.
79 Functionality: Show the Impact List and allow the Applicant to select any item related to this project.
80 (Help text) Additional debris removal costs include but are not limited to: travel, meals, miscellaneous, donated.
81 Functionality: Only ask if FEMA is preparing the estimate.
82 Functionality: Applicant’s cost estimate should be derived based on the bid or contract amount. Requested, not required.
83 Functionality: Flag for Recipient and FEMA review of method used to determine costs to be reasonable.
84 Functionality: Show Employee List from previously provided employee information on other project applications and allow Applicants to select an employee or add employees to the list. Optional field if only claiming equipment cost.
85 Functionality: Donated labor sign in sheet required if donated was listed as a resource type.
86 Functionality: Mutual aid agreement required if mutual aid was listed as a resource type.
87 (Help Text) Select appropriate rate type. If multiple rates are paid to this employee on this project, populate hours separately by rate type. For Permanent Work and Debris Removal, both straight-time and overtime labor costs are eligible for both budgeted and unbudgeted employee hours. For Emergency Protective Measures, only overtime labor is eligible for budgeted employee hours. For unbudgeted employees both straight-time and overtime labor are eligible. See the Labor section of the PAPPG. Functionality: For Applicant Employees, auto-calculate based on employee’s rate plus fringe benefit from Grants Portal Registration. Optional field if only claiming equipment cost.
88 Functionality: Allow the applicant to provide all dates and hours related to this project.
89 Functionality: Only show if Applicant selected “Equipment Rate”.
90 Functionality: Calculate based on rates and hours.
91 (Help text) Include year, make model, size, and capacity. For more information, please see the Applicant-Owned and Purchased Equipment section of the PAPPG. Functionality: Generate from Equipment Information in the Organization Profile. If applicant entered, populate information in the Equipment Information list.
92 (Help text) Please upload invoice. Functionality: If “Purchased” is selected, do no request hourly rate and the number of hours. Documentation required prior to reconciliation.
93 (Help text) Please upload rental agreement. Include the cost for fuel if applicable and upload fuel receipt. Functionality: If “Rented” is selected, do no request hourly rate and the number of hours. Documentation required prior to reconciliation.
94 (Help text) Please provide the total number of miles claimed. Functionality: If mileage is selected, use GSA rate. If Equipment Rate is selected, generate based on either FEMA or SLTT rate. If the rate is local or FEMA, use the lower of the two. If the rate is a state, territorial, or tribal rate, use the rate provided it does not exceed $75. If there is no rate for the equipment listed, notify the PAGS.
95 Functionality: Populate question only if Applicants selects Purchased Equipment.
96 Functionality: Flag for Recipient and FEMA review of method used to determine costs to be reasonable.
97 Functionality: Request invoices/receipts, except for donated selection.
98 (Help text) Applicants select least cost alternative when the claimed cost is less than the cost to repair the facility to pre-disaster design and function. The cost of materials and supplies is eligible if (1) the materials or supplies were purchased and justifiably needed to effectively address the described threats or (2) the materials or supplies were taken from an Applicant's stock and used to address threats caused by the specified hazard or threat. The Applicant needs to track items taken from stock with inventory withdrawal and usage records. FEMA will also consider escalation of costs (such as due to shortages) or exigent circumstances in evaluating cost reasonableness.
99 (Help text) Please provide donor name. Functionality: Applicants submitting donated resources must provide donor name.
100 (Help text) When equipment or supplies (including materials) purchased with PA funding are no longer needed for response to or recovery from the incident, the Applicant may use the items for other federally funded programs or projects, provided the Applicant informs FEMA. Tribal and local governments and PNPs must calculate the current fair market value of each individual item of equipment. Fair market value is either the selling price or the advertised price for a similar item in a competitive market. The Applicant must provide the current fair market for any items that have a current fair market value of $5,000 or more. FEMA reduces eligible funding by this amount.
101 Functionality: Calculate based on quantity x unit price.
102 Functionality: Only ask if donated was selected.
103 Functionality: Populate question only if Applicants selects Purchased.
104 (Help text) Other costs may include travel costs (including meals and incidentals), utilities and other expenses directly tied to the performance of eligible work. Not all costs incurred as a result of the incident are eligible. See the Public Assistance Program and Policy Guide for detailed requirements on Ineligible Costs.
105 (Help text) Please provide a meal/per diem policy. If no policy is available, explain why meals were provided.
106 (Help text) Please provide vendor or donor name.
107 Functionality: Calculate total cost.
108 Functionality: Generate costs from the General Cost and Work Status Information section.
109 (Help text) Please provide a meal/per diem policy. If no policy is available, explain why meals were provided.
110 (Help text) and Functionality: Applicants submitting projects must choose one of the following: donated buildings, donated land, or donated space.
111 Functionality: Optional not required.
112 Functionality: Automate based on date submitted.
113 Functionality: The Recipient completes this section prior to submission to FEMA. Do not include this section on Recipient project applications.
114 Functionality: Automated based on date submitted.
115 Functionality: Only show this section if the work is 100% complete.
116 Functionality: If selected, instruct the Applicant to the General Cost and Work Status Information section to provide the final costs and upload supporting documentation.
117 Functionality: Generate Work Completed date from the Large Project QPR. If certificate is created or submitted after the deadline prompt a Closeout Extension Request.
118 Functionality: Automate based on date submitted.
119 Functionality: Automate based on date submitted.
FEMA
Form XXX-X-XX
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | [email protected] |
| File Modified | 0000-00-00 |
| File Created | 2023-09-06 |
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