Form FF-104-FY-21-165 ( FF-104-FY-21-165 ( Principal's Advisor's Report

DEPARTMENT OF HOMELAND SECURITY

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

PRINCIPLE ADVISOR'S REPORT

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 3 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 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.
Management of Forest and Grassland Fires, Section 420 PL 93-288, as amended
2. DATE AND TIME OF STATE
REQUEST

1. NAME OF PRINCIPAL ADVISOR

3. DATE AND TIME OF
ADVISOR'S REPORT

4. I HAVE/HAVE NOT REVIEWED THE OFFICIAL STATE REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION UNDER
SECTION 420, PL 93-288.
I HAVE REVIEWED

I HAVE NOT REVIEWED
Date Fire Started

Name of Fire
5. PREVAILING WEATHER CONDITIONS:
TEMPERATURE

HUMIDITY

6. FIRE INDEX (Palmer, KBDI, Haines, etc.)
WIND

NAME OF INDEX

OTHER
:

NUMBER ON SCALE

7. PREDICTION OF WEATHER AND FIRE CONDITIONS FOR THE NEXT 24 HOURS: (Fire Behavior)

8. WILDFIRES:
a. EXISTENCE OF OTHER FIRES NEARBY THAT MAY RESULT IN A CONFLAGRATION

b. NUMBER OF LARGE FIRES BURNING IN THE STATE:
9. THREAT INFORMATION:
a. ASSESSMENT

b. PROXIMITY OF FIRE TO HOMES AND COMMUNITIES:

c. NATURAL OR OTHER BARRIERS BETWEEN FIRE AND COMMUNITIES:

10. THIS ASSESSMENT IS BASSED ON
ON SITE SURVEY

DISCUSSION WITH THE INCIDENT COMMANDER

OTHER (specify)

12. TELEPHONE NUMBER
11. Signature of Principle Advisor

a. Day

13. FEDERAL AGENCY
FEMA FORM FF-104-FY-21-165 (formerly 078-0-2)
(07/21)

b. Other (cell, pager)

c. Night

14. OFFICE LOCATION (City, State, ZIP)

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Privacy Notice Form Request for Principal Advisor's Report

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 U.S. Forest Service or Bureau of Land management professional fire
fighter/Principal Advisor.
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, and according to 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-21-165 (formerly 078-0-2)
(07/21)

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