FF-104-FY-23-101 Project Application for Emergency Protective Measures

DEPARTMENT OF HOMELAND SECURITY

OMB Control Number:1660-0058
Expiration Date: XX/XX/XXXX

Federal Emergency Management Agency

PROJECT APPLICATION FOR EMERGENCY PROTECTIVE MEASURES
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 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 (1660-0058) NOTE: Do not send your completed form to this address.

DRAFT
PRIVACY ACT STATEMENT

The collection of this information is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 403 and
420; 42 U.S.C. 5187; Title 44 Code of Federal Regulations (C.F.R.) § 204; and 2 C.F.R. § 200. This information is being collected to
provide assistance to eligible jurisdictions to facilitate the response to and recovery from a Fire Management Assistance Grant
declaration. 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 Fire Management Assistance Program.

PRIVACY ACT STATEMENT

Emergency Protective Measures includes activities that eliminate or lessen immediate threats to lives, public health, or safety; or
threats of significant damage to improved public or private property. FEMA uses this form to collect information necessary to support
the Applicant's claim. For more information, please see Chapter 3: Eligibility in the the Fire Management Assistance Grant Program
and Policy Guide or contact the State, local, Tribal, or Territorial emergency management office for additional information. 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:
• When, where, and by whom the activities were completed
• Actual cost information

SECTION 1 - APPLICANT INFORMATION
Declaration Number:

Legal Name of Applicant:

FEMA PA ID:

SECTION 2 - PROJECT INFORMATION
Project Number:

Applicant-Assigned Project Number (Optional):

Project Title:

Project Amendment Number:

Period of Performance Deadline:

Work Type:
Emergency Protective Measures

Incident Period:

Location(s):

Please describe the emergency protective measures conducted:
Please provide work start and end dates (MM/DD/YYYY)-(MM/DD/YYYY):

-

What resources did the Applicant use to complete the work? (Please select all that apply)
Contracts
Equipment: Force Account. Was this pre-approved by FEMA?
Yes (Please upload FEMA pre-approval documentation)
No
Equipment: Rented. Was this pre-approved by FEMA?
Yes (Please upload FEMA pre-approval documentation)
No
Materials and Supplies: Force Account. Was this pre-approved by FEMA?
Yes (Please upload FEMA pre-approval documentation)
No
FEMA Form FF-104-FY-23-101 (6/23)

Labor: Force Account
Travel

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CONTRACTED COSTS
Contract Description and Source:
Does the Applicant wish to input its Contracts into FEMA's Summary Record?
Yes
No: Provide Total Costs Claimed:
(Please upload a summary sheet with the pertinent information)
(Please upload a copy of each awarded contract, bid package, any change orders, and invoices)
CONTRACT WORK SUMMARY RECORD
Contractor:
Description of Work Performed:
Dates Worked:
Amount:

DRAFT

TOTAL COST

Invoice Number:
Date Paid:

EQUIPMENT: FORCE ACCOUNT

Force Account Equipment Description and Source:
Applicant-owned
Purchased

Is the Applicant claiming mileage or hourly rate?
Mileage
FEMA Equipment Rate
Local Equipment Rate (Please upload supporting documentation)

Does the Applicant wish to input its Force Account Equipment into FEMA's Summary Template?
Yes
No: Provide Total Force Account Equipment Costs Claimed:
(Please upload a summary sheet with
the pertinent information)
(Please upload documentation to support all Force Account Equipment costs and FEMA pre-approval)
EQUIPMENT: FORCE ACCOUNT SUMMARY RECORD
Type of Equipment (indicate size, capacity, horsepower, make, and model as appropriate):
Equipment Code Number:

Equipment Rate:
TOTAL HOURS

Operator's Name:
Date:

TOTAL COST

Hours:
EQUIPMENT: RENTED

Rented Equipment Description:
Is the Applicant claiming mileage or hourly rate?
Mileage
FEMA Equipment Rate
Local Equipment Rate (Please upload supporting documentation)
Does the Applicant wish to input its Rented Equipment into FEMA's Summary Template?
Yes
No: Provide Total Rented Equipment Costs Claimed:
(Please upload a summary sheet with the
pertinent information)

FEMA Form FF-104-FY-23-101 (6/23)

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EQUIPMENT: RENTED SUMMARY RECORD
Type of Equipment (indicate size, capacity, horsepower, make, and model as appropriate):
Vendor:

Invoice Number:

Amount:

Date Paid:

Equipment Code Number:

Equipment Rate:

TOTAL HOURS

TOTAL COST

Operator's Name:
Date:

Hours:

DRAFT
LABOR: FORCE ACCOUNT

Force Account Labor Description and Source:

Does the Applicant wish to input its Force Account Labor into FEMA's Summary Template?
Yes
No: Provide Total Force Account Labor Costs Claimed:
(Please upload a summary sheet with
the pertinent information)
(Please upload documentation to support all Force Account Labor costs)

LABOR: FORCE ACCOUNT SUMMARY RECORD

Type of Individual:
Donated Labor
Applicant Employee
Mutual Aid
Emergency Management
Assistance Compact (EMAC).
(Please upload the following
documents:
• EMAC Resource
Support Agreement
• R-1 form
• R-2 form
• Signed Proof of Payment)
Other:

Rate Type:
Straight Time

Date(s):

Overtime
Premium
Hazard

TOTAL HOURS

TOTAL COST

Hours:

Straight Time Fringe
Benefits (Percentage)
Overtime Fringe
Benefits (Percentage)

MATERIALS AND SUPPLIES: FORCE ACCOUNT
Force Account Materials and Supplies Description and Source:
Does the Applicant wish to input its Materials and Supplies into FEMA's Summary Template?
Yes
No: Provide Total Materials and Supplies Costs Claimed:
(Please upload a summary sheet with
the pertinent information)
(Please upload documentation to support all Force Account Material and Supply costs)

FEMA Form FF-104-FY-23-101 (6/23)

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MATERIALS AND SUPPLIES: FORCE ACCOUNT SUMMARY RECORD
Material Description:
How was the material obtained?
Purchased
From Stock

Quantity Purchased:

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 (Specify):

Vendor:
Quantity Used:

Unit Price:

Purchased Date
(MM/DD/YYYY):

Used Date
(MM/DD/YYYY):

Fair Market Value:

Total Cost:
Donated Value:
Total Cost:

DRAFT
SECTION 3 - SCOPE OF WORK AND COST SUMMARY

Scope of Work:

COST BREAKDOWN

Contract:

Applicant's own employees:

Labor

Mutual Aid:
Applicant's own equipment:

Equipment

Purchase equipment:
Rented equipment:
Stock materials:

Materials

Purchased materials:
Travel:

Additional Infrastructure
Restoration Costs

Meals:
Miscellaneous:

Grand Total

SECTION 4 - 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)

Please provide any additional information, comments, or a brief description of the uploaded documentation, if applicable:

FEMA Form FF-104-FY-23-101 (6/23)

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SECTION 5 - APPLICANT PROJECT ACKNOWLEDGEMENTS AND CERTIFICATIONS
I acknowledge and certify that I have reviewed and understand the following information regarding overarching
requirements to receive Fire Management Assistance Grant 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, compliance with environmental and historic preservation laws, and inclusion of required
provisions as applicable.
The requirement to comply with all Fire Management Assistance Grant Program applicable statutes. The statute that
authorizes FEMA to provide assistance through the Public Assistance Program is the Robert T. Stafford Disaster Relief
and Emergency Assistance Act, as Amended (Stafford Act), Title 42 of the United States Code (U.S.C.) § 5187 et seq.

DRAFT

The requirement to comply with Fire Management Assistance Grant Program rules and regulations as described in 44
C.F.R. Part 204.
The requirement to comply with applicable administrative requirements, cost principles, and audit requirements in 2
C.F.R. Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards.
The requirement to comply with applicable policies which are used to articulate FEMA's intent and direction in applying
statutory and regulatory authority to achieve desired outcomes. Compliance with the Fire Management Assistance Grant
Program and Policy Guide (FMAG-PPG) is also required. The purpose of the FMAG-PPG is to define FEMA's Public
Assistance Program and its policy and procedural requirements. When the FMAG-PAPPG uses the words “must” or
“required,” it is a legal requirement.
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.
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, I certify 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 Fire Management Assistance Grant 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 Fire Management Assistance Grant 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).

FEMA Form FF-104-FY-23-101 (6/23)

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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 SLTT
government Recipients and Applicants unless there is evidence of fraud. Section 705 does not apply to Private Nonprofit 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.
APPLICANT SIGNATURE
Applicant Authorized Representative:

Title:

Signature:

Date Submitted:

DRAFT
SECTION 6 - RECIPIENT RECOMMENDATION

Does all work in this project meet the criteria to be eligible for Fire Management Assistance Grant funding?
Yes
No (Describe Why):
Has the Applicant completed all of the work associated with the project?
Yes
No
Work Completed Date (MM/DD/YYYY) (Please update if changed):

I certify that I have reviewed and understand the following information regarding overarching requirements to receive Fire
Management Assistance Grant 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 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.
RECIPIENT SIGNATURE
Recipient Authorized Representative:

Title:

Signature:

Date Submitted:

FEMA Form FF-104-FY-23-101 (6/23)

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