FF-104-FY-23-103 Time Extensions

DEPARTMENT OF HOMELAND SECURITY

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

Federal Emergency Management Agency
TIME EXTENSION REQUEST
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.

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.

DRAFT
PRIVACY ACT STATEMENT

Time extensions are changes to the original grant agreements. This form shows all information and documentation that is needed for
FEMA to process the request. Please contact your FEMA Regional office for additional information. All signatures are official and
legally binding.
In general, this form will collect certain time extension information including:
• Declaration-level information
• Time extension details and justification
• Proposed deadline

SECTION 1 - APPLICANT INFORMATION

Declaration Number:

Legal Name of Applicant:

FEMA PA ID:

SECTION 2 - TIME EXTENSION REQUEST

Recipients and Applicants complete a time extension request for each type of time extension

TIME EXTENSION TYPE
Please select the time extension type:
Prime Award Period of Performance Deadline
Project Worksheet Submittal Deadline
Closeout Liquidation Period Deadline/Closeout Submittal Deadline
Current Deadline (MM/DD/YYYY):

Date Requested (MM/DD/YYYY):

Please provide the justification for the extension (Please upload any supporting documentation):

RECIPIENT SIGNATURE
Recipient Authorized Representative:

Title:

Signature:

Date Submitted:

FEMA Form FF-104-FY-23-103 (6/23)

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