Form FF-104-FY-21-167 ( FF-104-FY-21-167 ( Request for FEMA Sub-Grant

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB Control No. 1660-0058
Expiration: June 30, 2025

REQUEST FOR FIRE MANAGEMENT ASSISTANCE SUBGRANT

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 18 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 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., Room 7NE, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0058) NOTE: Do not send your
completed form to this address.
1.a DUNS NUMBER
1. APPLICANT (Political subdivision or eligible applicant)
2. DATE

3. COUNTY (location of firefighting activities. If located in multiple counties, please indicate)

APPLICANT PHYSICAL LOCATION
1. STREET ADRESS

3. COUNTY

2. CITY

4. STATE

Primary Contact/Applicant's Authorized Agent

5. ZIP CODE

Alternate Contact

1. NAME

1. NAME

2. TITLE

2. TITLE

3. BUSINESS PHONE

3. BUSINESS PHONE

4. FAX NUMBER

4. FAX NUMBER

5. HOME PHONE

5. HOME PHONE

6. CELL PHONE

6. CELL PHONE

7. EMAIL ADDRESS

7. EMAIL ADDRESS

8. PAGER & PIN NUMBER

8. PAGER & PIN NUMBER

Title 44 CFR part 204.41 defines Fire Management Assistance eligibility criteria as: (a) The following entities are eligible to apply through a
State grantee for a subgrant under an approved fire management assistance grant: 1) State agencies; 2) Local government; and 3) Indian
tribal governments. (b) Entities that are not eligible to apply for a subgrant as identified in(a), such as privately owned entities and volunteer
fire fighting organizations, may be reimbursed through a contract or compact with an eligible applicant for cost associated with the fire
complex. (c) Eligibility is contingent upon the finding that the applicant's resources were requested by the Incident Commander or comparable
State official. (d) The activities performed must be the legal responsibility of the applying entity, required as a result of the fire complex for
which a fire management assistance declaration was approved, and located within the declared area.
FEMA FORM FF-104-FY-21-167 (formerly 089-0-24)
(07/21)

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Privacy Notice Form Request for Fire Management Assistance Subgrant

AUTHORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records within this form under the Section 420 of the Robert T.
Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5187 and §303 of the Disaster Mitigation Act of 2000.
PRINCIPAL PURPOSE: FEMA is collecting this information to determine which state(s), local, tribal, or territorial government(s) are eligible for
Fire Management Assistance Grants. FEMA collects information from the political subdivision and/or the public agency, as well as the
applicant's authorized representative.
ROUTINE USES: FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their grant
applications, as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, including pursuant to routine uses
published in DHS/FEMA/PIA - 013 Grant Management Programs (February 19, 2015).
DISCLOSURE: The disclosure of this information is voluntary, however, failure to furnish this information may result in a delay of FEMA
assistance.

FEMA FORM FF-104-FY-21-167 (formerly 089-0-24)
(07/21)

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