Form FF-104-FY-21-166 ( FF-104-FY-21-166 ( Request for FIre Management Assistance Grant (FMAG) Decl

DEPARTMENT OF HOMELAND SECURITY

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

REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1 hour 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. STATE
2. DATE OF REQUEST
3. TIME OF REQUEST
4. NAME OF GOVERNOR OR AUTHORIZED REPRESENTATIVE
5. AGENCY REPRESENTED

PHONE NO. INCLUDING AREA CODE
b. Night
a. Day
ADDRESS (Street, City, Zip)

NOTE: In making this request, the Government agrees to abide by provisions contained in FEMA-State Agreement for Fire Management
Assistance under Section 420, PI 93-288 as amended. This request must be signed below by the Governor personally or by his authorized
representative, whom he has previously authorized to sign this request in the FEMA - State Agreement.
TITLE

6. SIGNATURE

DATE

I. EXISTING CONDITIONS
7.
EXISTENCE OF
HIGH
FIRE DANGER
CONDITIONS

a. TEMPERATURE

c. DIRECTION AND VELOCITY OF WIND

b. RELATIVE HUMIDITY

d. PREVAILING WEATHER CONDITIONS AND PREDICTIONS FOR NEXT 24 HOURS

8. NUMBER OF WILD FIRES
a. CONTROLLED

ACRES BURNED

b. UNCONTROLLED

ACRES BURNED

c. EXISTENCE OF OTHER FIRES NEARBY WHICH LIMITS THE COMMITMENT OF STATE FIRE FIGHTING
RESOURCES #
d. EXISTENCE OF OTHER FIRES NEARBY THAT MAY RESULT IN A
CONFLAGRATION #
9. INDICIES
10. BURN BANS
NATIONAL FIRE DANGER RATING
SYSTEM
OTHER (KBDI, SPI, HAINES, PALMER,
ETC.)

YES

NO

11. NATIONAL WATCHES

WARNINGS
YES

NO

YES

NO

II. FIRE SITUATION REPORT
12. TIME OF REPORT

13. NAME OF UNCONTROLLED FIRE

15. LOCATION OF UNCONTROLLED FIRE: (County)

14. DATE

16. ACRES BURNING:
a. FEDERAL

%

b. STATE

%

c. PRIVATE

%

17. MANPOWER AND RESOURCES COMMITTED (Attach separate sheet if necessary)
STATE:

LOCAL:

18. TYPE AND AMOUNT OF FEDERAL OR OTHER ASSETS & RESOURCES NEEDED: (FEMA does not order resources)

FEMA FORM FF-104-FY-21-166 (formerly 078-0-1)
(07/21)

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III. CURRENT THREAT
19. THREAT TO LIFE:

a. PREPARATIONS MADE FOR EVACUATION? b. PERSONS EVACUATED:
YES

#

NO

20. NAME AND LOCATION OF COMMUNITY THREATENED

ADDITIONAL INFORMATION

TOWN

CITY

#

SUBDIVISION
21. CASUALTIES

22. THREAT TO PRIVATE PROPERTY (Dwellings)

1. CIVILIAN LOSS OF LIFE

1. NUMBER OF HOMES

2. CIVILIANS INJURED

a. % OF PRIMARY

3. FIRE FIGHTERS LOSS OF
LIFE

b. % OF SECONDARY

4. FIRE FIGHTERS INJURED
23. THREAT TO FACILITIES (Include number when applicable)
AMOUNT

TYPE

AMOUNT

BUILDINGS

RECREATION

ROADS & BRIDGES

EQUIPMENT

INFASTRUCTURE

BUSINESS

UTILITIES

OTHER

TYPE

ADDITIONAL INFORMATION

24. THREAT TO RESOURCES
WATERSHED

WILDLIFE (Type threatened, fur-bearing animals, big game, etc.)

IRRIGATION

ENVIRONMENTAL RESOURCES (bio-diverse areas, etc.)

FLOOD CONTROL

CULTURAL RESOURCES

FISHING STREAMS & SPAWNING SITES

ECONOMIC INJURY

ADDITIONAL INFORMATION

IV. STATE ASSESSMENT
25. EMERGENCY MANAGEMENT ASSESSMENT OF THE SITUATION

DATE

SIGNATURE
26. FORESTRY ASSESSMENT OF THE SITUATION

DATE

SIGNATURE
FOR FEMA REGIONAL USE ONLY
SIGNATURE
FEMA FORM FF-104-FY-21-166 (formerly 078-0-1)
(07/21)

TITLE

DATE
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Privacy Notice Form Request for Fire Management Assistance Declaration

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 governor of the state or the governor's authorized representative in
order to allow FEMA to contact the grant applicants in order to complete grant applications.
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-21-166 (formerly 078-0-1)
(07/21)

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