Form FEMA Form FF-104-F FEMA Form FF-104-F Project Application for Infrastructure Restoration

Public Assistance Program

FF-104-FY-22-242_Project Application for Infrastructure Restoration_Final

Project Application for Infrastructure Restoration

OMB: 1660-0017

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DShape1 EPARTMENT OF HOMELAND SECURITY OMB Control Number FF-104-FY-22-242

Federal Emergency Management Agency Expires Month Day, Year


PROJECT APPLICATION FOR INFRASTRUCTURE RESTORATION

Paperwork Burden Disclosure Notice

Public reporting burden for this data collection is estimated to average 44 minutes 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 (1660-0017) 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, §§ 402-403, 406-407, 417, 423, 427, 428, 502, and 705; 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e, 5189f, 5192, 5205; 44 C.F.R. § 206 Subpart G; and 2 C.F.R. § 200. This information is collected to provide assistance to eligible jurisdictions and organizations to facilitate the response to and recovery from a Presidentially-declared disaster or emergency, or to provide assistance for hazard mitigation measures during the recovery process. 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 Public Assistance program.


Purpose and Applicability

Permanent Work (Categories C–G) includes activities required to restore a facility to its pre-disaster design (size and capacity) and function in accordance with applicable codes and standards. FEMA uses this form to collect information necessary to support the Applicant’s claim. To see all information and documentation that may be requested to substantiate work or costs or for more information, please see Chapter 8 Permanent Work Eligibility in the Public Assistance Program and Policy Guide and the Public Assistance Resource Library. Please contact the State, local, Tribal, or Territorial emergency management office for additional information.

Recipients and Applicants should use PA Grants Portal to submit all documentation and information to FEMA. 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 [will be] completed

  • Estimated or actual cost information

  • Effects on environmental, floodplain, and historic resources


Section I – Impact Groups and Project Information


Impact Groups


Based on previously provided information, the identified impact(s) have been grouped into a project. 1 [system generated]


Do the grouped impact(s) need to be modified? 2

No

Yes.3 Please provide reason for modifying grouped impacts:      


What is the total cost associated with the newly grouped impact(s)? [system generated] Applicant will be prompted to complete Small Project Information or Large Project Information based upon answers provided.



Declaration & Applicant Information4


Declaration # [system generated]

Legal Name of Applicant: [system generated]

FEMA PA ID: [system generated]


Project Information5


Project #6

[system generated]

Applicant-Assigned Project #7 (optional)

Project Title: 8


Project Amendment #9 [system generated]

Period of Performance deadline: 10 [system generated]

Work Type: Infrastructure Restoration


Impact line item(s) final grouping [system generated]


Facility Type(s) 11 [system generated]

Facility Name(s) 12 [system generated]

Site/Campus Name(s) 13 [system generated]

Location(s) 14 [system generated]


Do you want to make this impact a high priority? High priority means that FEMA will work with you to address this impact before any others you list. 15 [system generated] Please update if changed.

No

Yes


Section II – Small Project16

This section is completed for projects with total costs less than the large project threshold.


Component Damage Description and Dimensions17

The information in this section is system generated from the Site Inspection Report/Damage Information.


Component: [system generated]

Component location: [system generated]


Incident Attribute: [system generated]


Cause of facility/component damage: [system generated]


Manufacturer’s name plate data: [system generated]


Type, style, model: [system generated]


Material: [system generated]


Quantity: [system generated] Unit of measure: [system generated]


Dimensions: Length: [system generated] Width: [system generated] Height: [system generated]


Make, model, year: [system generated]

Capacity, size, horsepower: [system generated]


Baseline Scope of Work18

The information in this section is system generated from the Site Inspection Report/Damage Information. The damage description and dimensions are applied to develop a baseline scope of work which the Applicant can build upon considering repair methods, incorporating resiliency, or integrating other changes to the original facility.


Component: [system generated]

Component location: [system generated]


Manufacturer’s name plate data: [system generated]


Type, style, model: [system generated]


Material: [system generated]


Quantity: [system generated] Unit of measure: [system generated]


Dimensions: Length: [system generated] Width: [system generated] Height: [system generated]


Make, model, year: [system generated]

Capacity, size, horsepower: [system generated]




Scope of Work Considerations


What is the Applicant’s plan for restoring the facility? Please select all that apply.

No changes to the baseline scope of work

Site investigation, survey, or preliminary design services needed to determine appropriate restoration method. Please describe:      

Repair facility with:

General improvements.19 Please describe:      

Change in materials. Please describe:      

Change in size or capacity. Please describe:      

Change the function.20 Please describe:      

Changes required by codes and standards. Please describe:      

Interior configuration. Please describe:      

Relocate the facility. 21 Please describe:      

Replace the facility. 22 Please describe:      

Abandon the facility. Please describe:      

Unsure23

Select to view a list of common mitigation measures that can be included in this project application.24 (link to mitigation list addendum)

Please describe the scope of work to restore the facility:      


Please describe any changes to the pre-disaster construction that are intended to reduce future damage to the restored facility:      25



General Cost and Work Status Information


Has the Applicant started any of the work activities claimed on this project application? [system generated] Please update if changed.

All work is complete Please provide work start and end dates (MM/DD/YYYY) - (MM/DD/YYYY).

Work has started and is approximately       % complete. Please provide the start date and a projected end date, if known: (MM/DD/YYYY) - (MM/DD/YYYY)

Work has not started. Please provide a projected start date: (MM/DD/YYYY)

Does the Applicant have insurance for this work? [system generated]

No, the facilities and work were not insured.

Yes, the Applicant anticipates receiving $      .

Yes, the Applicant received $      .

Yes, but the Applicant is uncertain of the amount it will receive.

Yes, but the insurance company denied the claim. Please provide an explanation of denied claim or upload denial correspondence.

Has [Does] the Applicant received [anticipate receiving] funding from another source for this work? [system generated] Please update if changed.

No

Yes. Please check all that apply:

Cash Donations. Please describe:       Amount $     

Federal Grants.26 Please describe:       Amount $      

Non-Federal Grants. Please describe:       Amount $      

Revenue. Please describe:       Amount $      

Third-Party Liability.27 Please describe:       Amount $      


Cost Estimate


Please upload an itemized cost estimate for this project. [system generated] Please include the number and type of resources necessary to complete the work.

What is the basis for the estimate?

Actual costs

Historical unit costs

Average costs for similar work in the area

Published unit costs from a national cost estimating database

Contractor or vendor quotes

Other.28 Please describe:      

What resources did [will] the Applicant use to complete the work? [system generated] Please select all that apply.

Contracted

Has the Applicant procured and selected a contractor?

No

Yes

How did the Applicant ensure the contract costs were reasonable?

Competitive procurement process

Cost or price analysis

Compared to historical costs for similar projects in the area

Other. Please describe:      


What is the total cost of contracted work?

Completed Cost

+

Future Cost

=

Total Cost

$

$

$


Labor

Applicant’s own employees

What is the total cost of employee labor?

Completed Cost

+

Future Cost

=

Total Cost

$

$

$


Mutual aid, prison labor, or national guard

What is the total cost of mutual aid, prison labor, or national guard?


Completed Cost

+

Future Cost

=

Total Cost

Mutual Aid

$

$

$

Prison Labor

$

$

$

National Guard

$

$

$


Equipment

Applicant’s own equipment

Purchased or rented equipment

Has the Applicant completed the purchase or rental?

No

Yes

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. Please describe:      


What is the total cost of equipment?

Completed Cost

+

Future Cost

=

Total Cost

$

$

$


Materials

From Stock

Purchased

Has the Applicant completed the purchase?

No

Yes

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. Please describe:      


What is the total cost of materials?

Completed Cost

+

Future Cost

=

Total Cost

$

$

$


Donated Resources29

Labor

Equipment

Materials

Buildings or Land

Permanent30

Temporary31

Space

Logistical Support


What is the total value?

Completed Value

+

Future Value

=

Total Value

$

$

$









Additional Infrastructure Restoration costs

Travel

Meals

Miscellaneous. Please describe:     


What is the total additional infrastructure restoration cost?

Completed Costs

$

+

Future Costs

$

=

Total Costs

$





Total Cost Claim32

$ [system generated]



Section III – Small Project Closeout Request


Has the Applicant completed all the work associated with the project?

No

Yes. Work Completed date: (MM/DD/YYYY)

Does the Applicant want to close this project or other small projects as well?

Applicant wants to closeout this project only33

Applicant wants to closeout multiple small projects34

Applicant wants to closeout all small projects35


The Applicant may request additional funding if its combined actual cost of all its Small Projects exceeded the combined cost FEMA approved for all its Small Projects. Does the Applicant wish to claim any costs that exceeded the total amount obligated? 36 [system generated for the small project with the latest period of performance]

No

Yes. Amount $      Please upload all documentation to support work and costs for all small projects.


Total approved amount [system generated]

Federal share obligated [system generated]

Date obligated [system generated]



Section IV – Large Project37

This section is completed for projects with total costs greater than the large project threshold.


Component Damage Description and Dimensions38

The information in this section is system generated from the Site Inspection Report/Damage Information.


Component: [system generated]

Component location: [system generated] 39


Incident Attribute: [system generated]


Cause of facility/component damage: [system generated]


Manufacturer’s name plate data: [system generated]


Type, style, model: [system generated]


Material: [system generated]


Quantity: [system generated] Unit of measure: [system generated]


Dimensions: Length: [system generated] Width: [system generated] Height: [system generated]


Make, model, year: [system generated]


Component: [system generated]

Component location: [system generated]


Baseline Scope of Work40

The information in this section is system generated from the Site Inspection Report/Damage Information. The damage description and dimensions are applied to develop a baseline scope of work which the Applicant can build upon considering repair methods, incorporating resiliency, or integrating other changes to the original facility.


Component: [system generated]

Component location: [system generated] 41


Manufacturer’s name plate data: [system generated]


Type, style, model: [system generated]


Material: [system generated]


Quantity: [system generated] Unit of measure: [system generated]


Dimensions: Length: [system generated] Width: [system generated] Height: [system generated]


Make, model, year: [system generated]

Capacity, size, horsepower: [system generated]


Scope of Work Considerations


What is the Applicant’s plan for restoring this facility?

No changes to the baseline scope of work

Site investigations, surveys, or preliminary design services needed to determine appropriate restoration method. 42

Repair the facility with:

Changes required by codes and standards43

General improvements44

Interior configuration

Change in materials

Change the size or capacity

Change the function45

Replace the facility.

Is it feasible to repair the facility?

No. Please describe why it is not feasible to repair the facility (e.g., apparent based on visual observation that the incident completely destroyed the facility):      

Replacement will trigger code or standard changes to pre-disaster design46

Applicant plans to relocate the facility47

Applicant is incorporating improvements not otherwise triggered by codes or standards.

Change materials

Change the size or capacity

Change the function48

Yes49

Abandon the facility50


Do any of the following apply to this work?51 Please select all that apply:

Construction feasibility issues

There is a less costly way to restore the facility than repairing it to pre-disaster design and function

Other unique construction circumstances: Please describe:     


Scope of Work Development


By default, FEMA or the Recipient develops the detailed scopes of work and cost estimates unless the Applicant elects to provide. If the Applicant provides the scope of work, FEMA or the Recipient will validate the scope of work and cost estimate. Does the Applicant wish to provide a detailed scope of work and cost estimate?

No. FEMA or the Recipient will develop the scope of work and estimate.

Yes. Please describe the scope of work to restore the facility or upload documentation with at least the same level of information:      .52 Please upload any design drawings, sketches, technical surveys, or reports.


Codes and Standards


Did [will] the work to restore the facility require work triggered by a code, specification, or standard?

No

Yes. Please select all that apply.

Consensus-based code, specification, or standard. 53

Did [will] the Applicant build to the triggered code, specification, or standard?

No, the Applicant will apply a locally-adopted code that is equivalent or more stringent than the consensus-based code. If selected, please upload documentation to justify this selection.

No, applying the consensus-based code, specification, or standard is technically infeasible and would create an extraordinary burden on the Applicant or would otherwise be inappropriate for the facility. Please describe why incorporating consensus-based standard is infeasible:       Please upload written certification by a registered engineer, design professional, or other qualified individual that the project cannot be designed and constructed to include applicable consensus-based codes, specifications, and standards.

Yes.

Americans with Disabilities Act (ADA) requirements. 54

Other Federal requirement.

The Applicant received a letter from the community floodplain administrator identifying the facility has been substantially damaged. 55

State, local, Tribe, or Territory adopted codes, specifications, or standards. Please describe and upload supporting documentation:      56


Mitigation


How does the Applicant intend to make changes to the pre-disaster construction to reduce future damage to the restored facility? 57

Common mitigation measure (link to mitigation list addendum). Please select all that apply.58

Other mitigation measure. Please describe the measure and how it protects the facility:      59

Not implementing Public Assistance hazard mitigation. Please describe:      

Unsure. Does the Applicant want technical assistance from FEMA to determine options for incorporating resiliency into the restoration scope of work? 60

No

Yes

By default, FEMA or the Recipient develops the detailed scopes of work and cost estimates unless the Applicant provides the information. If the Applicant provides the scope of work, FEMA or the Recipient will validate the scope of work and cost estimate. Does the Applicant wish to provide a detailed scope of work and cost estimate for hazard mitigation measures?

No. FEMA or the Recipient will develop the scope of work and estimate.

Yes. Please describe the hazard mitigation scope of work or upload documentation:       Please upload any design drawings, sketches, technical surveys, or reports. 61



Replacement Project62

The information in this section is system generated from the Pre-Approval Request.


Date of request of approval: [System generated]63


Describe in detail the intended scope of work or upload documentation with at least the same level of information: [System generated] 64


Alternative Procedures – Use of excess funds

The information in this section is system generated from the Pre-Approval Request.


Date of request of approval: [System generated] 65


Describe in detail the intended scope of work or upload documentation with at least the same level of information: [System generated]


Alternate Project

The information in this section is system generated from the Pre-Approval Request.


Date of request of approval: [System generated] 66


Describe in detail the intended scope of work or upload documentation with at least the same level of information: [System generated] 67


Improved Project

The information in this section is system generated from the Pre-Approval Request.


Date of request of approval: [System generated]68


Describe in detail the intend scope of work or upload documentation with at least the same level of information: [System generated]


Environmental and Historical Preservation Information


[Link to the Environmental and Historic Preservation Addendum for a list of applicable questions]


General Cost and Work Status Information69


Has the Applicant started any of the work activities claimed on this project application? [System generated]70 Please update if changed.

All work is complete.71 Please provide work start and end dates (MM/DD/YYYY) - (MM/DD/YYYY).

Work has started and is approximately       % complete. Please provide the start date and a projected end date, if known: (MM/DD/YYYY) - (MM/DD/YYYY)

Work has not started. Please provide a projected start date: (MM/DD/YYYY)


Please indicate what type of cost was used for this project: [system generated] Please select all that apply:

Actual cost. Please complete actual cost table below.

Estimate for future cost. [required by licensed professional]

Estimated contracted cost: $     

Estimated labor cost: $     

Estimated equipment cost: $     

Estimated materials cost: $     

Estimated other costs: $     


Does the Applicant have insurance for this facility?72 [System generated] Please update if changed.

No, the facilities and work were not insured.

Yes, the Applicant anticipates receiving $      .

Yes, the Applicant received $      .

Yes, but the Applicant is uncertain of the amount it will receive. 73

Yes, but the insurance company denied the claim. Please upload denial correspondence. 74 [required]

Has [Does] the Applicant received [anticipate receiving] funding from another source for this work? 75 [System generated] Please update if changed.

No

Yes. Please check all that apply:

Cash Donations. Please describe:       Amount $      

Federal Grants. 76 Please describe:       Amount $      

Non-Federal Grants. Please describe:       Amount $      

Revenue. Please describe:       Amount $      

Third-Party Liability.77 Please describe:       Amount $      



Actual Cost Information


Impact Line Item: 78Please select one. [system generated list of Impacts]


What resources did the Applicant use to complete the work? Please select all that apply.

Contracted

Labor

Equipment

Materials

Additional infrastructure restoration costs


Contracted Costs


Please complete the Contract Information form for all contracts that have an estimated value of more than $1,000,000. 79

Has the Applicant procured and selected a contractor? 80

No

Yes. 81 How did the Applicant ensure the contract costs were reasonable? Please upload a copy of the awarded contract, bid package, any change orders, and invoices.

Cost or price analysis

Compared to historical costs for similar projects in the area

Obtained multiple quotes

Other.82 Please describe:      


Labor and Equipment


Name of Individual     83

Donated labor84

Applicant employee

Mutual aid85

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 type86 [optional if only claiming equipment]

Straight time $     

Overtime $     

Premium $     

Hazard $     

Date(s)

     

Hours87

     

Total hours: 88      [system calculated]

Labor hours:      [system calculated]

Equipment hours:      [system calculated]


Total Cost89

Labor cost $     [system calculated]

Equipment cost $     [system calculated]

Donated value $     [system calculated]



Equipment Description and source     90

Applicant owned

Purchased91

Rented92

Donated      

Is the Applicant claiming mileage or hourly rate? 93

Mileage      

Equipment $     


How did the Applicant ensure the purchased equipment costs were reasonable? 94

Cost or price analysis

Compared to historical costs for similar projects in the area

Obtained multiple quotes

Other.95 Please describe:      


Materials96


Material description

     

How was the material obtained? 97

Donated      98

Purchased

From Stock99

Purchased Date (MM/DD/YYYY)      

Used Date (MM/DD/YYYY)      


Quantity Purchased

     

Unit Price

     

Quantity Used

     

Fair Market Value

     

Total Cost100

Donated value $      [system calculated]

Total cost $      [system calculated]


How did the Applicant ensure the purchased material costs were reasonable? 101

Cost or price analysis

Compared to historical costs for similar projects in the area

Obtained multiple quotes

Other. Please describe:      


Additional infrastructure restoration costs102


Description

Travel      

Meals     103

Miscellaneous. Please describe:     

Donated      104

Permanent105

Temporary106

Vendor/Donor

     

Purchased/Donated Date      

Used Date

     

Quantity Purchased/ Donated

     

Fair Market Value

     

Total Cost

      [system calculated]

Public Assistance Hazard Mitigation Cost Information


Cost to restore the facility without mitigation or applicant-driven improvements: $      

Total hazard mitigation cost $       Please upload a cost estimate prepared by a licensed professional engineer or other estimating professional or FEMA will develop based on either the awarded contract or accepted bid; or use the Cost Estimating Format.

Facility restoration costs eliminated by incorporating hazard mitigation $      107

Net Hazard Mitigation cost $      108

Net Hazard Mitigation Cost / Total Restoration Cost $      x 100 = [      % which is < 15% or      % which is >15%] [      % which is < 100% or       % which is >100%]109

Does the Applicant want the Recipient or FEMA to assist with the benefit cost analysis? 110

No, the Applicant will submit the benefit cost analysis.

Yes


Expert Panel Review of Cost Estimate111

Applicants complete this section if the total project cost, including mitigation is equal to or more than $5,000,000 Federal share and work is not complete.


Does the Applicant want a third-party expert panel review of the estimate? 112

No

Yes


Strategic Funds Management


Will all funds be needed within 180 days? 113

No.114 Please upload a plan for expending the funds, including projected dates for when and how much funding is needed.

Yes


Section V – FEMA’s Fixed Cost Offer115


PA Mitigation Estimate116 [system generated]

Project Restoration Estimate117

[system generated]

Fixed Cost Offer Amount118 [system generated]


Fixed Cost Offer Transmittal Date119 [system generated]

Fixed Cost Offer Deadline120 [system generated]


Does the Applicant accept this offer for a fixed cost estimate?

No121

Yes122


Applicant Authorized Representative [system generated]

Title [system generated]

Signature [system generated]

Date Submitted123 [system automated]


Section VI – Scope of Work and Cost Summary


Work Summary


Scope of Work: [system generated]


Mitigation Scope of Work: [system generated]

Improved Project Scope of Work: [system generated]


Replacement Project Scope of Work: [system generated]

Alternative Procedures Scope of Work: [system generated]


Alternate Project Scope of Work: [system generated]


Closeout Project Scope of Work: [system generated] 124


Cost Breakdown


Estimated Costs

Closeout Final Costs


[system calculated below]


Contract:      


Labor:

Applicant’s own employees:      

Mutual Aid:      


Equipment:

Applicant’s own equipment:      

Purchased equipment:      

Rented equipment:      


Materials:

Stock materials:      

Purchased materials:      


Additional infrastructure restoration costs

Travel      

Meals      

Miscellaneous      


Deductions:

Insurance:      

Other sources:      


[system calculated below]


Contract:      


Labor:

Applicant’s own employees:      

Mutual Aid:      


Equipment:

Applicant’s own equipment:      

Purchased equipment:      

Rented equipment:      


Materials:

Stock materials:      

Purchased materials:      


Additional infrastructure restoration costs

Travel      

Meals      

Miscellaneous      


Deductions:

Insurance:      

Other sources:      




Donated Resources:

Labor:      

Equipment:      

Material:      

Buildings or Land:      

Space:      

Logistical Support:      


Donated Resources:

Labor:      

Equipment:      

Material:      

Buildings or Land:      

Space:      

Logistical Support:      


Hazard Mitigation Cost:      

Hazard Mitigation Cost:      


Grand total:      

Grand total:      


Section VII – 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. 125

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

Section VIII –Applicant Project Acknowledgements and Certifications

I acknowledge and certify that I have reviewed and understand the following information regarding overarching requirements to receive Public 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; Federal procurement and contracting laws in accordance with 2 C.F.R. §§ 200, compliance with the Environmental Protection Agency guidelines for procurement of recovered materials; environmental and historic preservation laws; and inclusion of required provisions as applicable.

      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 the Stafford Act § 311, 42 U.S.C. §5154, 44 C.F.R § 206.251-253, and in accordance with FEMA Policy 206-086-1 Public Assistance Policy on Insurance, I acknowledge I must obtain and maintain insurance coverage for all buildings, contents, equipment, and vehicles in an amount equal to or greater than the total cost, prior to any reductions.

      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 200.404, 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.

      Compliance with all codes and standard requirements and all State, local, Tribe, or Territory codes or standards as required by the Stafford Act § 406(e), 42 U.S.C. § 5172(e); 44 C.F.R. § 206.226(d).

      That I have a routine maintenance program for facilities and have a written maintenance plan and/or activity logs documenting regular intervals of activity.

      All activities on private property must have completed all necessary legal processes and obtained rights-of-entry and agreements to indemnify and hold harmless the Federal Government.

      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 Public 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 Public 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).

Applicant acknowledgements for alternative procedure project126

I acknowledge that I have reviewed and understand the following information regarding Alternative Procedure Permanent Work Projects. Please initial next to each statement.

      FEMA does not incorporate funds from temporary relocation projects or any other emergency protective measures into fixed cost projects.

      The Applicant may not revert to a project funded based on actual costs.

      If Public Assistance Hazard Mitigation funding is added to the project, and the Applicant does not complete the approved mitigation, FEMA deobligates the portion of the fixed cost amount related to hazard mitigation.

      Once the fixed cost amount is obligated, FEMA considers it reasonable and eligible, as long as there is no evidence of fraud, and the Applicant complies with Federal award conditions.

      The Applicant acknowledges that failure to notify FEMA prior to making SOW changes that involve buildings or structures that are 45 years of age or older, ground disturbing activities, or work in or near waterways could result in loss of funding.

      The Applicant waives its appeal rights unless it is related to a cost adjustment made by FEMA after the Fixed Cost Offer is accepted.

      FEMA will adjust the fixed estimate to account for actual insurance proceeds as described in the Insurance Proceeds sections of the Public Assistance Program and Policy Guide.

Applicant signature

Applicant Authorized Representative [system generated]

Title

[system generated]

Signature

[system generated]

Date Submitted127 [system generated]

Section IX – Project/Amendment Recipient Recommendation128

Does all work in this project meet the criteria to be eligible for Public Assistance funding?

No. Please describe why:      

Yes

Recipient Authorized Representative [system generated]

Title

[system generated]

Signature

[system generated]

Date submitted [system automated]

Section X- Large Project Closeout Applicant Request129

Has the Applicant completed all the work associated with the project?

No

Yes. Proceed to the General Cost and Work Status Information section to provide the final costs and upload supporting documentation.

Section XI - Alternative Procedures Closeout Request

What resources did the Applicant use to complete the work? Please select all that apply and provide a summary of total costs.

Applicants own labor, equipment, material: $     

Contracted: $     

Purchased or Rented: $     

Donated labor, equipment, material, buildings, or lands: $     


Has the Applicant received funding from another source for this work?

No

Yes

Insurance $     

Other $     

Work Completed date (MM/DD/YYYY) [system generated] Please update if changed.

Total approved amount [system generated]

Federal share obligated [system generated]

Date obligated [system generated]

Capped Project [system generated]


Section XII – Applicant Closeout Acknowledgments and Certifications

I acknowledge and certify that I have reviewed and understand the following information regarding overarching requirements to receive Public Assistance. Please initial next to each statement.

      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 Non-profit 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 Authorized Representative [system generated]

Title [system generated]

Signature [system generated]

Date submitted [system automated]

Section XIII – Recipient Closeout Acknowledgements and Certification

I certify that I have reviewed and understand the following information regarding overarching requirements to receive Public 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 accordance with the FEMA approved scopes of work, and that the project is 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 Authorized Representative [system generated]

Title [system generated]


Signature [system generated]


Date submitted

[system automated]


1 Functionality: Generate default groupings based on the line items selected on the Impact List Addendum. Display all impacts within each group.

2 Functionality: Allow Applicant and/or PDTFL to modify groupings.

3 Functionality: Reason for modifying grouped impacts required. Notify PDTFL to evaluate whether the reason aligns with PAPPG logical grouping. Display all impacts based on selections in the Impact List Addendum and allow each impact to be re-grouped. Do not allow line items marked as “all work is complete” to be combined with line items that are not complete.

4 Functionality: Generate Declaration #, Legal Name of Applicant, and PAID from the RPA.

5 Functionality: Generate Declaration # from the Incident Information. Generate Legal Name of Applicant, and FEMA PA ID from the Organization Profile.

6 Functionality: Assign a Project number.

7 (Help text) The Applicant may assign a unique title and number for each project application. This title and number may help the Applicant connect this project application to their accounting or other systems..

8 (Help text) Applicant may assign a unique title to each Project Application for internal tracking purposes. Functionality: Optional, not required.

9 Functionality: Assign a Project Amendment number.

10 Functionality: Automate based on standard period of performance deadlines by category and any approved time extensions.

11 Functionality: Generate from the Impact List.

12 Functionality: Generate from the Impact List.

13 Functionality: Generate from the Impact List.

14 Functionality: Generate from the Impact List.

15Functionality: Generate from “Do you want to make this impact a high priority?” in the Impact List. Show the highest priority level of all selected impacts (i.e., if some are “high” and some are “standard”, overall project says “high”).

16 (Help text) The simple approach is the fastest way to request FEMA funding and requires the least documentation. Under the simple approach, once an Applicant's Request for Public Assistance is approved, the Applicant will have 21 days to review information about eligibility for Public Assistance and an additional 60 days to submit all claims to FEMA. Once submitted, simplified claims typically take 30-60 days to process. This option is only available for projects totaling up to $1,000,000. Generate EHP Addendum if any EHP triggers were identified in the Impact List.

17 Functionality: Autogenerate from the Damage Information

18 Functionality: Create baseline SOW from inverse of Damage Description and Dimensions.

19 Functionality: Trigger the Improved Project section of the Request for Approval.

20 Functionality: Trigger the Alternate Project section of the Request for Approval.

21 Functionality: Trigger the Replacement Project section of the Request for Approval.

22 Functionality: Trigger the Replacement Project section in the Request for Approval.

23 Functionality: Flag for PDMG, if one is assigned, or PAGS, if a direct applicant and Recipient.

24 (Help text) Changes to the facility that do not meet codes and standard but offer resiliency against future incidents are considered mitigation. Please see the Mitigation Addendum for a list of considerations that can be applied during repairs. Functionality: Generate a link to the Mitigation Addendum

25 Functionality: Auto-generate selected options the Applicant selected on the Hazard Mitigation Addendum.

26 (Help text) See the Non-Federal Grants and Cash Donations section in the PAPPG for more information.

27 (Help text) See the Third-Party Liability section in the PAPPG for more information.

28 Functionality: Flag for Recipient and FEMA review of the estimating methodology.

29 (Help text) and Functionality: Applicants submitting projects must choose one of the following: donated buildings, donated land, or donated space.

30 (Help text) For buildings or land donated permanently (i.e., with a transfer of ownership), offset is based on the fair market value at the time of donation as established by an independent appraisal and certified by the Applicant.

31 (Help text) For building or land space donated for temporary use, the offset is based on the fair rental value of comparable privately-owned space in the same locality as established by an independent appraisal.

32 Functionality: Calculate based on the sum of the Total Costs minus the Total Funds.

33 Functionality: Generate Applicant and Recipient Closeout Acknowledgements and Certifications Sections

34 Functionality: Generate list of available small projects and allow the Applicant to select multiple small projects.

35 Functionality: Auto-select all small projects.

36 Functionality: Generate this question if Applicant wants to close all small projects was selected. (More Info) Applicants may request additional funding within 60 days of the work completion on its last small project.

37 (Help text) The itemized approach enables Applicants to catalog damages, group claims, and provide detailed information to substantiate specific types of costs. The itemized approach is required for Applicants with total claims greater than the large project threshold may be suitable for Applicants who are unsure of what claims are eligible for reimbursement. Under the itemized approach, Applicants should expect to meet with FEMA within 21 days of the approval of their Request for Public Assistance and should expect to itemize damages, collect documentation, and submit claims within 60-70 days. In some cases, based on the nature and complexity of work, this process may take longer. Once submitted, itemized claims typically take 45-90 days to process. This option is available for all Applicants and required for Applicants with claims totaling more than the large project threshold. Generate EHP Addendum if any EHP triggers were identified in the Impact List.

38 Functionality: Generate from Damage Information Form.

39 (Help text) Please list the specific location of the component in relation to the overall facility, such as a room or area of the facility, or item specific GPS coordinates. GPS coordinates should be latitude and longitude values in decimal degrees formatted to the sixth decimal place (e.g., 38.885431, -77.018781)

40 Functionality: Create baseline SOW from inverse of Damage Description and Dimensions.

41 (Help text) Please list the specific location of the component in relation to the overall facility, such as a room or area of the facility, or item specific GPS coordinates. GPS coordinates should be latitude and longitude values in decimal degrees formatted to the sixth decimal place (e.g., 38.885431, -77.018781)

42 Functionality: This should not be combined with other line items.

43 Functionality: Trigger the Code and Standard section below.

44 (Help text) The Applicant may wish to make improvements to a damaged facility that are not required by eligible codes or standards. A project that restores the pre-disaster function of a facility and incorporates improvements or changes to the pre-disaster design is an Improved Project. FEMA limits Federal funding for an Improved Project to the lesser of either the Federal share of the approved estimate to restore the damaged facility to its pre-disaster design and function or the Federal share of the actual costs of completing the Improved Project. This should not be combined with other line items. Functionality: Trigger the Improved Project section in the Request for Approval.

45 Functionality: Trigger the Alternate Project section of the Request for Approval.

46 Functionality: Trigger the Code and Standard section below.

47 Functionality: Trigger the Replacement Project section of the Request for Approval.

48 Functionality: Trigger the Alternate Project section of the Request for Approval.

49 (Help text) The cost to repair the disaster-related damage must exceed 50 percent of the cost to replace the facility based on its pre-disaster size, capacity, and function. See Repair vs. Replacement section of the PAPPG for more information. Functionality: Trigger Replacement Project section in the Request for Approval.

50 Functionality: Trigger the Alternate Project section of the Request for Approval.

51 (Help text) Examples may include changes required due to access issues, site conditions, or to tie into existing infrastructure. The changes must not impact the capacity or function of the facility.

52 (Help text) You may upload documentation with at least the same level of information. Functionality: Requested, not required.

53 (Help text) Minimum codes, specifications, and standards for repair and replacement of eligible facilities are the latest published editions of relevant consensus-based codes, specifications, and standards that incorporate the latest hazard-resistant designs and establish minimum acceptable criteria for the design, construction, and maintenance of facilities for the purpose of protecting the health, safety, and general welfare of the facilities’ users against incidents.

54 (Help text) See the Accessibility for Individuals with Disabilities section in the PAPPG.

55 Functionality: Option triggered if building is selected on the Impact List Addendum.

56 (Help text) To be eligible, the codes and standards must: Apply to the type of restoration required; be appropriate to the pre-disaster use of the facility; Be found reasonable, in writing, and formally adopted and implemented by the State, local, or Tribal government on or before the disaster declaration date or be a legal Federal requirement applicable to the type of restoration; Apply uniformly to all similar types of facilities within the jurisdiction of the owner of the facility; Be in effect and enforced at the time of an incident. See the Codes and Standards section in the PAPPG.

57 (Help text) See the Hazard Mitigation section of the PAPPG and FEMA’s Mitigate Disaster Damage with FEMA Public Assistance brochure. (More info – only if project is for completed work) Mitigation work may still be eligible for Public Assistance funding even after the Public Assistance funded repair is complete; however, FEMA will not provide Public Assistance funding for any duplicative work triggered by the subsequent mitigation.

58 (Help text) See Hazard Mitigation Addendum for selection options. Functionality: Generate Hazard Mitigation Addendum.

59 Functionality: Generate the information entered in the “Other” option from the Hazard Mitigation Addendum, if provided.

60 Functionality: If project application is submitted without mitigation flag for Recipient and PA Group Supervisor.

61 Functionality: Documentation required prior to submission of the Project Application.

62 Functionality: Triggered if “Replace the facility” is selected in the Description of Activities section. All Replacement project applications must go through Recipient Application Review for Recipient approval of the replacement request prior to being submitted to FEMA.

63 Functionality: Generate from Request for Approval Form only if approved.

64 Functionality: Generate intended scope of work from the Request for Approval Form only if approved.

65 Functionality: Generate from Request for Approval Form only if approved.

66 Functionality: Generate from Request for Approval Form only if approved.

67 Functionality: Generate intended scope of work from the Request for Approval Form only if approved.

68 Functionality: Generate from Request for Approval Form only if approved.

69 Functionality: Generate from the Impact List.

70 Functionality: The Applicant may update this section any time prior to submitting a project completion certification. If work is 100% complete upon submission, populate closeout section.

71 Functionality: Do not allow this activity to be combined with activities that do not have this box checked.

72 (Help text) Applicants are required to take reasonable efforts to recover insurance proceeds that it is entitled to receive from its insurers. FEMA will consider final insurance settlements that may be less than the insurance policy limits when an applicant demonstrates that it has taken reasonable efforts to recover insurance proceeds that it is entitled on a case-by-case basis. See Recovery Policy FP 206-086-1, Public Assistance Policy on Insurance for more information.

73 (Help text) FEMA may reduce the total estimated project cost by an estimated amount of insurance proceeds based on a review of the Applicant’s insurance policy.

74 Functionality: Documentation required prior to submission of the Project Application.

75 (Help text) FEMA is legally prohibited from duplicating benefits from other sources. If the Applicant receives funding from another source for the same work that FEMA funded, FEMA reduces the eligible cost or de-obligates funding to prevent a duplication of benefits. See Section 312 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act for more information.

76 (Help text) See the Non-Federal Grants and Cash Donations section in the PAPPG for more information.

77 (Help text) See the Third-Party Liability section in the PAPPG for more information.

78 Functionality: Show the Impact List and allow the Applicant to select any item related to this project. For Management Costs allow Applicant to select from the list of activities previously indicated in Section III of the Project Application.

79 (Help text) Section 1224(e) of the Disaster Recovery Reform Act requires FEMA to collect and store information, prior to the project closeout phase on any contract entered into by a Public Assistance Recipient or Applicant that throughout the base award, available options, or any subsequent modification has an estimated value of more than $1,000,000.

80 Functionality: Only ask if FEMA is preparing the estimate.

81 Functionality: Applicant’s cost estimate should be derived based on the bid or contract amount. Requested, not required.

82 Functionality: Flag for Recipient and FEMA review of method used to determine costs to be reasonable.

83 Functionality: Allow Applicants to select an employee previously provided on the Staff, Equipment, and Facility Inventory form or allow the Applicant to update the form. Optional field if only claiming equipment cost.

84 Functionality: Donated labor sign in sheet required if donated was listed as a resource type.

85 Functionality: Mutual aid agreement required if mutual aid was listed as a resource type.

86 (Help Text) Select appropriate rate type. If multiple rates are paid to this employee on this project, populate hours separately by rate type. For Permanent Work and Debris Removal, both straight-time and overtime labor costs are eligible for both budgeted and unbudgeted employee hours. For Emergency Protective Measures, only overtime labor is eligible for budgeted employee hours. For unbudgeted employees both straight-time and overtime labor are eligible. See the Labor section of the PAPPG. Functionality: For Applicant Employees, auto-calculate based on employee’s rate plus fringe benefit from Grants Portal Registration. Optional field if only claiming equipment cost.

87 Functionality: Allow the applicant to provide all dates and hours related to this project.

88 Functionality: Only show if Applicant selected “Equipment Rate”.

89 Functionality: Calculate based on rates and hours.

90 (Help text) Include year, make model, size, and capacity. For more information, please see the Applicant-Owned and Purchased Equipment section of the PAPPG. Functionality: Generate from Equipment Information list in the Organizational Profile. If applicant entered, populate information in the Equipment Information list.

91 (Help text) Please upload invoice. Functionality: If “Purchased” is selected, do no request hourly rate and the number of hours. Documentation required prior to reconciliation.

92 (Help text) Please upload rental agreement. Include the cost for fuel if applicable and upload fuel receipt. Functionality: If “Rented” is selected, do no request hourly rate and the number of hours. Documentation required prior to reconciliation.

93 (Help text) Please provide the total number of miles claimed. Functionality: If mileage is selected, use GSA rate. If Equipment Rate is selected, generate based on either FEMA or SLTT rate. If the rate is local or FEMA, use the lower of the two. If the rate is a state, territorial, or tribal rate, use the rate provided it does not exceed $75. If there is no rate for the equipment listed, notify the PAGS.

94 Functionality: Populate question only if Applicants selects Purchased Equipment.

95 Functionality: Flag for Recipient and FEMA review of method used to determine costs to be reasonable.

96 Functionality: Request invoices/receipts for select material items.

97 (Help text) Applicants select least cost alternative when the claimed cost is less than the cost to repair the facility to pre-disaster design and function. The cost of materials and supplies is eligible if (1) the materials or supplies were purchased and justifiably needed to effectively address the described threats or (2) the materials or supplies were taken from an Applicant's stock and used to address threats caused by the specified hazard or threat. The Applicant needs to track items taken from stock with inventory withdrawal and usage records. FEMA will also consider escalation of costs (such as due to shortages) or exigent circumstances in evaluating cost reasonableness.

98 (Help text) Please provide donor name. Functionality: Applicants submitting donated resources must provide donor name.

99 (Help text) Applicants using materials from their stock do not need to provide Vendor Name.

100 Functionality: Calculate based on quantity x unit price.

101 Functionality: Populate question only if Applicants selects Purchased.

102 (Help text) Other costs may include travel costs (including meals and incidentals), utilities and other expenses directly tied to the performance of eligible work. Not all costs incurred as a result of the incident are eligible. See the Public Assistance Program and Policy Guide for detailed requirements on Ineligible Costs.

103 (Help text) Please provide a meal/per diem policy. If no policy is available, explain why meals were provided.

104 (Help text) and Functionality: Applicants submitting projects must choose one of the following: donated buildings, donated land, or donated space.

105 (Help text) For buildings or land donated permanently (i.e., with a transfer of ownership), offset is based on the fair market value at the time of donation as established by an independent appraisal and certified by the Applicant.

106 (Help text) For building or land space donated for temporary use, the offset is based on the fair rental value of comparable privately-owned space in the same locality as established by an independent appraisal.

107 (Help text) Costs eliminated refers to mitigation items that will be substituted for pre-disaster design items.

108 Functionality: Calculate based on the Total hazard mitigation cost minus the Facility Restoration Costs eliminated by incorporating hazard mitigation.

109 Functionality: Use the first bracket calculation for mitigation measures that are not on the PAPPG Appendix as depicted in the Hazard Mitigation Addendum. If this calculation is >15%, trigger the benefit-cost analysis. Use the second bracket calculation for mitigation measures that are on the PAPPG Appendix as depicted by † on the Hazard Mitigation Addendum. If the amount is >100%, trigger the benefit-cost analysis.

110 (Help text) FEMA considers mitigation measures to be cost-effective if the Recipient or Applicant demonstrates through an acceptable Benefit-Cost Analysis methodology that the measure is cost-effective. To help complete an analysis within the required guidelines, please use the Benefit-Cost Analysis Toolkit and upload the file. Additionally, FEMA has pre-calculated analyses for eligible projects. For assistance using the BCA Toolkit, including troubleshooting technical issues, email questions to the BCA Helpline or call toll free at 1-855-540-6744. See the Hazard Mitigation section in the PAPPG for more information. Functionality: Generate question if BCA is needed.

111 Functionality: Trigger this section if the total project cost, including mitigation is equal to or more than $5 million Federal share and work is not complete. Do not trigger this section if the cost is equal to or more than $25 million Federal share. Route all projects equal to or more than $25 million Federal share to the expert panel.

112 (Help text) See Expert Panel Review section in the PAPPG.

113 Functionality: Only ask for permanent work estimates that equal or exceed the large project threshold.

114 (Help text) This project will be awarded based on the Applicant’s schedule to execute the work. See FEMA’s Strategic Funds Management – Implementation Procedures for the Public Assistance Program for additional information.

115 Functionality: Only include for large, estimated projects, based on the large project threshold for this incident.

116 Functionality: Generate from Cost Breakdown.

117 Functionality: Generate from Cost Breakdown.

118 Functionality: Calculate based on Hazard Mitigation Estimate plus Project Restoration Estimate.

119 Functionality: Generate date offer sent to Applicant and Recipient for review.

120 Functionality: Generate 30 days from date offer sent to applicant for review, but only up to 18 months from the declaration date.

121 (Help text) FEMA will process this project as a Standard Project. FEMA will obligate the project based on the estimated amount in the offer and adjust the amount upon certification of completion of the project based on actual eligible costs.

122 (Help text) By accepting the Fixed Cost Offer, the Applicant is agreeing to an Alternative Procedures Permanent Work Project. Once the Applicant accepts this fixed cost offer, it may not revert to a project funded based on actual costs.

123 Functionality: Automate based on date submitted.

124 Functionality: Trigger this if the Applicant has selected YES to “Does the Applicant want to begin the closeout process for this project? In the Large Project Closeout Request section.

125 Functionality: Optional not required.

126 Functionality: Only include if the Applicant selected yes to accepting the fixed cost offer.

127 Functionality: Automate based on date submitted.

128 Functionality: The Recipient completes this section prior to submission to FEMA. Do not include this section on Recipient project applications.

129 Functionality: Only show this section if the work is 100% complete.


FEMA Form FF-104-FY-22-242



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
Author[email protected]
File Modified0000-00-00
File Created2023-11-03

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