Form FEMA Form FF-112-F FEMA Form FF-112-F Request for Special Priorities Assistance

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB Control Number: 1660-0149
Expiration: 01 31, 2024

REQUEST FOR SPECIAL PRIORITIES ASSISTANCE
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average .5 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 the form. This
collection of information is required to obtain or retain benefits. You are not required to submit to this collection of information unless it displays
a valid OMB control number. 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 (FEMA), 500 C Street
SW, Washington, DC 20472, and Paperwork Reduction Project (1660-NW122). NOTE: Do not send your completed form to this address.
PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(e)(3), this Privacy Act Statement serves to inform you of why DHS is requesting the information on this form.
AUTHORITY:
FEMA is authorized to collect the information requested on this form pursuant to Title I of the Defense Production Act of 1950 (DPA), as
amended (50 U.S.C. 4501, et seq.) as implemented by the Emergency Management Priorities and Allocations System (EMPAS) regulation
(44 CFR 333) and Section 602 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) (42 U.S.C. 5195a).
PURPOSE:
Use of FEMA Form 009-0-142 serves to structure the information concerning EMPAS problems so that it can be presented in writing to the
appropriate EMPAS Delegate agency and EMPAS officials for assistance and resolution. Each item of information requested is needed to
enable these officials to take appropriate action to resolve EMPAS problems on a case-by-case basis. The information requested includes
identification of the government program or end-product, the involved parties (customer, supplier, etc.), contract or purchase order
information, description of the items required, use of the items, current shipment schedule, and description of problem and urgency of
requirement.
ROUTINE USES:
The information requested on this form may be shared externally as a “routine use” to other Federal Government agencies; State, local, and/
or Tribal entities; and/or contractors to assist the Department of Homeland Security in resolving issues with rated orders pursuant to the
Defense Production Act and FEMA's EMPAS regulations. A complete list of the routine uses can be found in the system of records notice
associated with this form, “DHS/ALL-021, Department of Homeland Security Contractors and Consultants” The Department's full list of system
of records notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.
USE
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:
Providing this information is mandatory if the applicant seeks special priorities assistance pursuant to EMPAS regulations at 44 CFR 333.
However, failure to provide this information may result in conflicts not being efficiently resolved pursuant to the EMPAS regulations.
Individuals who do not provide this information may continue to be held to contract requirements without assistance in resolving conflicts.

Submission of a completed application is required to Request for Special Priorities Assistance (SPA). See
sections 333.20-24 of the Emergency Management Priorities and Allocations System (EMPAS) regulation
(44 CFR 333). It is a criminal offense under 18 U.S.C. 1001 to make a willfully false statement or
representation to any U.S. Government agency as to any matter within its jurisdiction. All company
information furnished related to this application will be deemed BUSINESS CONFIDENTIAL under Sec.
705(d) of the Defense Production Act of 1950 [50 U.S.C. 4455(d)] which prohibits publication or disclosure
of this information unless the President determines that withholding it is contrary to the interest of the
national defense. FEMA will assert the appropriate Freedom of Information Act (FOIA) exemptions if such
information is the subject of FOIA requests. The unauthorized publication or disclosure of such information
by Government personnel is prohibited by law. Violators are subject to fine and/or imprisonment.

FEMA FORM FF-112-FY-23-100 (formerly 009-0-142) (04/20)

CASE NO.
RECEIVED
ASSIGNED TO
Page 1 of 6

1. APPLICANT INFORMATION
a. Name and complete address of Applicant (Applicant can
be any person needing assistance - Government agency,
contractor, or supplier. See definition of "Applicant" in
Footnotes section on last page of this form).

Applicant Name

b. If Applicant is not end-user Government agency, give name and complete
address of Applicant's customer.

Customer Name
Address

Address
City

City
State

Zip

Contact's Name

Zip

Contact's Name
Title

Title

Telephone

Telephone

State

Fax No.

Fax No.

Email address

Email address

Contract/purchase order no.
Dated

Priority rating

2. APPLICANT ITEM(S)
If Applicant is not end-user Government agency, describe item(s) to be delivered by Applicant under its customer's contract or purchase
order through the use of item(s) listed in Block 3. If known, identify Government program and end-item for which these items are required. If
Applicant is end-user Government agency and Block 3 item(s) are not end-items, identify the end-item for which the Block 3 item(s) are
required. See definition of "item" in Footnotes section on last page of this form.

USE

3. ITEM(S) (including service) FOR WHICH APPLICANT REQUESTS ASSISTANCE
Quantity

Pieces, units

Description

Include identifying information such as model or part number

FEMA FORM FF-112-FY-23-100 (formerly 009-0-142) (04/20)

Dollar Value

Each quantity listed

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4. SUPPLIER INFORMATION
a. Name and complete address of Applicant's Supplier.

b. Applicant's contract or purchase order to Supplier.

Supplier Name

Number

Address

Dated

City

State

Zip

Priority rating

(If none, so state)

Contact Name

If Supplier is an agent or distributor, give complete producer or lower tier
supplier information in Continuation Block on page 5, including purchase order
number, date, and priority rating (if none, so state).

Title
Telephone

Fax No.

Email address

5. SHIPMENT SCHEDULE OF ITEM(S) SHOWN IN BLOCK 3
a. Applicant's original
shipment/performance
requirement
b. Supplier's original
shipment/performance
promise
c. Applicant's current
shipment/performance
requirement
d. Supplier's current
shipment/performance
promise

Month
Year

Total
units

Number of
units
Month
Year

Total
units

Number of
units
Month
Year

Total
units

Number of
units
Month
Year

USE

Total
units

Number of
units

6. REASONS GIVEN BY SUPPLIER for inability to meet Applicant's required shipment or performance date(s).

7. BRIEF STATEMENT OF NEED FOR ASSISTANCE. As applicable, explain effect of delay in receipt of Block 3 item(s) on achieving timely
shipment of Block 2 item(s) (e.g., production line shutdown), or the impact on program or project schedule. Describe attempts to resolve problems and give
specific reasons why assistance is required. If priority rating authority is requested, please so state.

FEMA FORM FF-112-FY-23-100 (formerly 009-0-142) (04/20)

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8. CERTIFICATION: I certify that the information contained in Blocks 1 - 7 of this form, and all other information attached, is correct and complete to the
best of my knowledge and belief (omit signature if this form is electronically generated and transmitted - use of name is deemed certification).

Signature of Applicant's authorized official

Title

Print or type name of authorized official

Date

9. U.S. GOVERNMENT AGENCY INFORMATION
a. Name/complete address of cognizant sponsoring
service/agency/activity headquarters office. Provide lower
level activity, program, project, contract administration, or
field office information in Continuation Block below, on
duplicate of this page, or on separate sheet of paper.

b. Case reference no.

Name

c. Government agency program or project to be supported by Block 2
item(s). Identify end-user agency if not sponsoring agency.

Address
City

State

Zip

Contact Name
Signature

Date

Title
Telephone

Fax No.

Email address
d. Statement of urgency of particular program or project and Applicant's
part in it. Specify the extent to which failure to obtain requested
USE
assistance will adversely affect the program or project.

e. Government agency/activity actions taken to attempt resolution of problem.

f. Recommendation

FEMA FORM FF-112-FY-23-100 (formerly 009-0-142) (04/20)

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g. ENDORSEMENT by authorized Department or Agency headquarters official (omit signature if this form is electronically generated and
transmitted - use of name is deemed authorization). This endorsement is required for all FEMA and foreign government requests for
assistance.

Signature of authorized official

Title

Type name of authorized official

Date
CONTINUATION BLOCK
Identify each statement with appropriate block number

USE

FEMA FORM FF-112-FY-23-100 (formerly 009-0-142) (04/20)

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INSTRUCTIONS FOR FILING FEMA FORM 009-0-142
NOTE: You may fill out this form using your computer. Save the downloaded blank file to your computer and generate forms for submission
via e-mail. Navigate between the form's data fields using the tab key, back tab, or backspace.
REQUESTS FOR SPECIAL PRIORITIES ASSISTANCE (SPA) MAY BE FILED for any reason in support of the Emergency Management Priorities and
Allocations System (EMPAS); e.g.: when its regular provisions are not sufficient to obtain delivery of item(s) (See Footnote 1 at the bottom of this page) in
time to meet urgent customer or program/project requirements; for help in locating a supplier or placing a rated order; to ensure that rated orders are receiving
necessary preferential treatment by suppliers; to resolve production or delivery conflicts between or among rated orders; to verify the urgency or determine the
validity of rated orders; or to request authority to use a priority rating.
Requests for SPA must be sponsored by the cognizant U.S. Government agency responsible for the program or project supported by the Applicant's
contract (See Footnote 2 at the bottom of this page) or purchase order.
REQUESTS FOR SPA SHOULD BE TIMELY AND MUST ESTABLISH:
• The urgent defense (including civil emergency) or project related need for the item(s); and that
• The Applicant has made a reasonable effort to resolve the problem.
APPLICANT MUST COMPLETE BLOCKS 1-8. SPONSORING U.S. GOVERNMENT AGENCY/ACTIVITY MUST COMPLETE BLOCKS 9-10.
WHERE TO FILE THIS FORM:
• Private sector Applicants should file with their respective customers as follows: lower-tier suppliers file with customer/subcontractor for forwarding to
subcontractor/prime contractor; subcontractors/suppliers file with prime contractor for forwarding to one of the below listed cognizant U.S.
Government (EMPAS Delegate) agencies; prime contractors file directly with one of the below listed cognizant U.S. Government (EMPAS Delegate)
agencies:
- Federal Emergency Management Agency (FEMA) -- File with the contracting officer in the agency's regional office or with its headquarters office in
Washington, D.C.
• Applicants who are lower level contract administration, program, project, or field offices, or when these activities cannot resolve the private
sector request for assistance, should forward this form to cognizant sponsoring service/agency/activity headquarters for review, Block 10 endorsement,
and forwarding to FEMA. Foreign government or private sector entities should file directly with FEMA. Timely review and forwarding is essential
to providing timely assistance.
• If for any reason the Applicant is unable to file this form as specified above, see CONTACTS FOR FURTHER INFORMATION below.
CONTACTS FOR FURTHER INFORMATION:
• For any information related to the production or delivery of items against particular rated contracts or purchase orders, contact the cognizant U.S.
Government agency, activity, contract administration, program, project, or field office (see WHERE TO FILE above).
• If for any reason the Applicant is unable to file this form as specified in WHERE TO FILE above, if the cognizant U.S. Government agency for filing
this form cannot be determined, or for any other information or problems related to the completion and filing of this form, the operation or administration
of the EMPAS, or to obtain a copy of the EMPAS or any EMPAS training materials, contact the FEMA, OPPA, 500 C Street, SW, Washington, D.C.
20472; telephone (202) 423-3770; [email protected].
SPECIAL INSTRUCTIONS:
USE
• If the space in any block is insufficient to provide a clear and complete
statement of the information requested, use the Continuation Block provided
on this form or a separate sheet to be attached to this form.
• Entries in Block 3 should be limited to information from a single contract or purchase order. If SPA is requested for additional contracts or purchase
orders placed with a supplier for the same or similar items, information from these contracts or purchase orders may be included in one application.
However, each contract or purchase order number must be identified and the quantities, priority rating, delivery requirements, etc., must be shown
separately.
• If disclosure of certain information on this form is prohibited by security regulations or other security considerations, enter "classified" in the
appropriate block in lieu of the restricted information.

FOOTNOTES:
1. "Item" is defined in the EMPAS as any raw, in process or manufactured material, article, commodity, supply, equipment, component, accessory, part,
assembly, or product of any kind, technical information, process, or service.
2. "Applicant" as used in this form refers to any person requiring Special Priorities Assistance, and eligible for such assistance under the EMPAS. "Person" is
defined in the EMPAS to include any individual, corporation, partnership, association, or any other organized group of persons, or legal successor or
representative thereof; or any State or local government or agency thereof; and for purposes of administration of this part, includes the Federal Government
and any authorized foreign government or international organization or agency thereof, delegated authority as provided in this part.

FEMA FORM FF-112-FY-23-100 (formerly 009-0-142) (04/20)

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