Request for Public Assistance

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DAMAGE INFORMATION
Paperwork Burden Disclosure Notice
Public reporting burden for this data collection is estimated to average 75 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 being 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
FEMA, Recipients, or Applicants complete this form during a site inspection to record detailed incident-related damage descriptions with dimensions. FEMA and the Recipient use this form to validate damage, scopes of work, and estimates. For more information, please see Chapter 5 Damage and Impact Information in the Public Assistance Program and Policy Guide or 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: 
    • Damaged components
    • Description and dimensions of the damage
    • Cause of damage
Section I – Declaration and Applicant Information1
Declaration # 
[system generated]
Legal Name of Applicant: [system generated]
FEMA PA ID: [system generated]
Section II – Site Information2
Facility Type(s) 
[system generated]
Facility Name(s) 
[system generated]
Site/Campus Name(s) [system generated]
Location(s) 
[system generated]
Is the facility currently inundated with flood waters or are other factors preventing inspection to determine visible damage?
☐ No 
☐ Yes. Please describe why it is inaccessible:        

Who will provide the damage inspection for this location? 3
☐ Applicant. Please provide estimated date of submittal to FEMA: (MM/DD/YYYY)
☐ Recipient. Please provide estimated date of submittal to FEMA: (MM/DD/YYYY)
☐ FEMA providing virtual assistance via phone or video conference with Applicant on-site. What date(s) and time(s) are preferable to conduct the site inspection? 4      
☐ FEMA on-site with Applicant. What date(s) and time(s) are preferable to conduct the site inspection? 5 Please provide point-of-contact and any additional information for the day of the inspection:      6
Section III – Facility Damage 
Please select the peril(s) which caused the damage. Please select all that apply.
☐ Earthquake7
☐ In-plane damage8
☐ Reinforcement failure9
☐ Short-column damage10
☐ Soft-story damage11
☐ Surface rupture12
☐ Explosion
☐ Fire
☐ Flame damage or combustion
☐ Smoke and particulate matter
☐ Soil hardening
☐ Thermal exposure
☐ Flooding13  

☐ Landslide14
☐ Mudslide15
☐ Severe storm16
☐ Lightning 
☐ Hail
☐ High winds 
☐ Wind-blown debris
☐ Wind-driven rain 
☐ Sewer backup 
☐ Snow or ice17
☐ Tsunami or tidal wave18
☐ Volcanic eruption19
☐ Wind
☐ Other. Please describe:      
Parks or Recreational Facilities20
Please describe the facility and how it was damaged:      
Damaged Components (with common material types). Please select all that apply.
☐ Athletic court
☐ Asphalt
☐ Concrete
☐ Composite
☐ Other. Please describe:      
☐ Athletic field surface
☐ Artificial
☐ Grass
☐ Other. Please describe:      
☐ Bleacher
☐ Fence
☐ Lighting
☐ Loss of fill
☐ Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:     
☐ Playground surface
☐ Power source and its electrical distribution and control system.
☐ Running track
☐ Other. Please describe:           
Detention basin, Sediment or debris basin, and Stormwater retention21
Please describe the facility and how it was damaged:      
What is the quantity of material deposited by the incident? Please include quantity:       and metric: 22        
☐ Actual     ☐ Estimate
Damaged Components (with common material types). Please select all that apply.
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:      
☐ Control gate
☐ Embankment 
☐ Dirt
☐ Gravel
☐ Sand
☐ Rock
☐ Other. Please describe:      
☐ Grate
☐ Lining
☐ Pipe
☐ Storm drain
☐ Weir
☐ Other. Please describe:      
Beaches, Dune23
Please describe the facility and how it was damaged:      
☐erm, Levee, Sand Revetment, Seawall24
Please describe the facility and how it was damaged:      
Damaged Components (with common material types). Please select all that apply.
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:      
☐ Control gate
☐ Core 
☐ Concrete
☐ Earth
☐ Metal
☐ Plastic
☐ Other. Please describe:      	
☐ Embankment 
☐ Dirt
☐ Gravel
☐ Sand
☐ Rock
☐ Other. Please describe:      
☐ Foundation 
☐ Rock
☐ Soil
☐ Other. Please describe: 
☐ Lining
☐ Loss of fill
☐ Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:      
☐ Pile
☐ Rebar
☐ Vegetative cover
☐ Weir
☐ Other. Please describe:      

Bridge25
Please describe the facility and how it was damaged: 26      
Number of lanes:      
Damaged Components (with common material types). Please select all that apply.
☐ Abutment
☐ Approaches
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:      
☐ Cross frame
☐ Loss of fill
☐ Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:      
☐ Barrier
☐ Deck
☐ Foundation
☐ Guardrail
☐ Girder
☐ Lighting
☐ Substructure
☐ Abutment
☐ Foundation
☐ Pier
☐ Surface 
☐ Asphalt
☐ Concrete
☐ Composite
☐ Chip & seal
☐ Dirt
☐ Gravel
☐ Other. Please describe:      
☐ Traffic signal
☐ Wingwall 
☐ Concrete
☐ Rock 
☐ Other. Please describe:      
☐ Other. Please describe:      
Building27
Please describe the facility and how it was damaged:      28
Please provide the estimated damaged square footage:      29 sq. ft. Please describe area:      30
Where is the damage to the building? 31
☐ Exterior
☐ Interior 

☐ Basement
☐ Other. Please describe:      
Damaged Components (with common material types). Please select all that apply.
☐ Bathroom components, please list and describe damage:       
☐ Ceiling
☐ Acoustical drop ceiling
☐ Blanket ceiling
☐ Ceiling tiles
☐ Drywall/sheet rock
☐ Insulation
☐ Plaster and lathe ceiling
☐ Unfinished ceiling
☐ Other. Please describe:      
☐ Electrical components, please list and describe damage:
     
☐ Elevator. Please describe:      
☐ Fire Protection, please list and describe damage:
     
☐ Doors
☐ Hollow core
☐ Metal
☐ Flat panel
☐ Raised panel
☐ Overhead 
☐ Painted
☐ Pre-finished
☐ Solid core
☐ Steel
☐ Stained
☐ Wood
☐ Flat panel
☐ Raised panel
☐ Flooring
☐ Carpet
☐ Ceramic
☐ Composition type (VCT)
☐ Painted Concrete
☐ Vinyl
☐ Wood
☐ Other. Please describe:      
☐ Foundation (spread footing, piles, etc.)
☐ HVAC
☐ Air conditioning unit
☐ Air handler
☐ Condenser
☐ Diffuser
☐ Duct work insulation 
☐ Duct work rigid
☐ Fan coil unit
☐ Furnace
☐ Gas
☐ Electric
☐ Heat Pump
☐ Other. Please describe:     
☐ Kitchen components, please list and describe damage:       
☐ Lighting
☐ Emergency Lighting
☐ Ceiling
☐ Recessed
☐ Other. Please describe:      
☐ Roofing32
☐ Roof accessories
☐ Ridge
☐ Continuous shingled ridge vent
☐ Metal
☐ Shingled
☐ Weather barrier type
☐ Asphalt felt 15#
☐ Asphalt felt 30#
☐ Other. Please describe:      
☐ Roof covering type. 
☐ Asphalt
☐ 3-Tab
☐ Multilayer
☐ Built-up (multi-ply)
☐ EPDM (ethylene propylene deine terpolymer) single ply
☐ Fluid applied roofing
☐ Metal
☐ Corrugated
☐ Ribbed
☐ Standing seam
☐ Other. Please describe:      
☐ PVC (polyvinyl chloride) single ply
☐ SBS modified (multi-ply)
☐ TPO (thermoplastic polyolefin) single ply
☐ Other. Please describe:      
☐ Roof type
☐ Gable
☐ Number of Gable:      
☐ Hip
☐ Number of Hip:      
☐ Other. Please describe:      
☐ Skylights
☐ Fiberglass panels
☐ Fixed dome type
☐ Operable type
☐ Septic components, please list and describe damage:       
☐ Structural element (column, beam, etc.)
☐ Walls
☐ Blanket wall insulation
☐ Concrete masonry unit (CMU)
☐ Drywall
☐ External siding
☐ Painted drywall
☐ Paneling
☐ Plaster
☐ Plaster and lathe wall
☐ Vinyl wall cover
☐ Wainscoting
☐ Other. Please describe:      
☐ Windows
☐ Awning
☐ Casement
☐ Double hung
☐ Fixed
☐ Louver
☐ Single hung
☐ Sliding
☐ Storm shutters
☐ Other. Please describe:      
☐ Other. Please describe:     

Cemetery33
Please describe the facility and how it was damaged:      
Damaged Components (with common material types). Please select all that apply.
☐ Casket
☐ Grave marker
☐ Loss of fill
☐ Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:     
☐ Other. Please describe:      
Communications System34
Please describe the facility and how it was damaged:      
Damaged Components (with common material types). Please select all that apply.
☐ Antenna 
☐ Cable 
☐ Conduit
☐ Electrical panel
☐ Electrical wire
☐ Guy wire
☐ Insulator
☐ Lines 
☐ Mast
☐ Network tower
☐ Pole
☐ Sensor
☐ Software/processor
☐ Supervisory control and data acquisition (SCADA)
☐ Terminal
☐ Transformer
☐ Vault/handhole
☐ Other. Please describe:        
Contents35
Please upload a list of damaged contents and describe how the contents were damaged:      
Culvert, Ditch36
Please describe the facility and how it was damaged:      37
Culvert type:
☐ Arch 
☐ Box/Rectangle (single or multiple)
☐ Bridge culvert
☐ Circular 
☐ Flat
☐ Horizontal ellipse 
 
☐ Metal box
☐ Pipe (single or multiple)
☐ Pipe arch (single or multiple)
☐ Vertical ellipse 
☐ Other. Please describe:      
Damaged Components (with common material types). Please select all that apply.
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:      
☐ Culvert pipe
☐ Aluminum
☐ Concrete
☐ Corrugated metal
☐ High-density polyethylene
☐ Polyvinyl chloride
☐ Steel
☐ Other. Please describe:      
☐ Headwall
☐ Concrete
☐ Rock 
☐ Other. Please describe:      
☐ Inlet
☐ Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:      
☐ Loss of fill
☐ Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:     
☐ Retaining Wall
☐ Concrete
☐ Rock 
☐ Other. Please describe:      
☐ Wingwall 
☐ Concrete
☐ Rock
☐ Other. Please describe:      
☐ Other. Please describe:      
Dam38
Please describe the facility and how it was damaged:      
What is the dam type?
☐ Arch
☐ Buttress
☐ Concrete
☐ Earth/rock embankments 
☐ Gravity
☐ Masonry 
☐ Multi-arch
☐ Rockfill
☐ Stone
☐ Timber crib
☐ Other. Please describe:      
Does the facility have a spillway?
☐ No
☐ Yes. What is the spillway type?
☐ Controlled
☐ Chute
☐ Ogee
☐ Shaft
☐ Side channel




☐ Siphon
☐ Uncontrolled
☐ Other. Please describe:      
Damaged Components (with common material types). Please select all that apply.
☐ Abutment
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:      
☐ Control gate
☐ Core 
☐ Concrete
☐ Earth
☐ Metal
☐ Plastic
☐ Other. Please describe:      
☐ Electrical panel
☐ Electrical wire
☐ Foundation 
☐ Rock
☐ Soil
☐ Other. Please describe:      
☐ Lining 
☐ Outlet gate 
☐ Bascule
☐ Drum
☐ Flag
☐ Needle
☐ Roller
☐ Slide/sluice gate
☐ Vertical lift
☐ Other. Please describe:      
☐ Overflow structure (Spillway)
☐ Sensor
☐ Supervisory control and data acquisition (SCADA)
☐ Weir
☐ Other. Please describe:      

Dock, Harbor, Pier, or Port39
Please describe the facility and how it was damaged:      
What was the type of inspection completed?  
☐ Above water
☐ Under water
☐ Structural integrity of piles
☐ Structural integrity of abutments
☐ Structural integrity of revetments
☐ In-situ borings
Damaged Components (with common material types). Please select all that apply.
☐ Abutment
☐ Anchor
☐ Boat ramp
☐ Dock
☐ Electrical power source and its distribution and control system, including grounding
☐ Fender system
☐ Frame and deck
☐ Gangway
☐ Light poles and fixture
☐ Mooring device
☐ Platform
☐ Revetment or other marine structure
☐ Other. Please describe:      
Drainage channel, Canal, Aqueduct40
Please describe the facility and how it was damaged:      
☐hat is the shape of the channel?
☐ Rectangular 
☐ Trapezoidal
☐ V-ditch
☐ Other. Please describe:      
What are the dimensions of the top of the channel or waterway?
Average Width:       feet
Average Depth:       feet
Length:       feet
What is the quantity of material deposited by the incident? Please include units:       and metric:      41
☐ Actual     ☐ Estimate
Damaged Components (with common material types). 42  Please select all that apply.
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:      
☐ Control gate
☐ Embankment 
☐ Dirt
☐ Gravel
☐ Sand
☐ Rock
☐ Other. Please describe:      
☐ Hydraulic structure
☐ Lining
☐ Vegetative Cover
☐ Weir
☐ Other. Please describe:      
Equipment, Supplies, or Vehicle43
Please upload a list of damaged equipment, supplies, and vehicles44 and describe how they were damaged:      
Lift station, Pumping station45
Please describe the facility and how it was damaged:      
What is the capacity of the pumping facility?      
How many generators are associated with the facility?      
How many pumps are associated with the facility?      
Damaged Components (with common material types). Please select all that apply.
☐ Electrical panel
☐ Electrical cables
☐ Emergency motor/generator set
☐ Holding tank
☐ Pipe
☐ Pump
☐ Sensor
☐ Supervisory control and data acquisition (SCADA)
☐ Transfer switch
☐ Other. Please describe:      
Low-water Crossing46
Please describe the facility and how it was damaged:      
Number of lanes:      
Damaged Components (with common material types). Please select all that apply.
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:       
☐ Base
☐ Dirt
☐ Gravel
☐ Sand
☐ Other. Please describe:      
☐ Embankment 
☐  Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:      
☐ Guardrail
☐ Headwall
☐ Concrete
☐ Rock 
☐ Other. Please describe:      
☐ Loss of fill 
☐ Dirt
☐ Gravel
☐ Rock 
☐ Sand
☐ Other. Please describe:      
☐ Retaining Wall 
☐ Concrete
☐ Rock
☐ Other. Please describe:      
☐ Subbase 
☐ Asphalt
☐ Concrete
☐ Composite
☐ Chip & seal
☐ Dirt
☐ Gravel
☐ Other. Please describe:      
☒ Surface 
☐ Asphalt
☐ Concrete
☐ Composite
☐ Chip & seal
☐ Dirt
☐ Gravel
☐ Other. Please describe:      
☐ Wingwall 
☐ Concrete
☐ Rock 
☐ Other. Please describe:      
☐ Other. Please describe:       
Natural gas transmission and distribution47
Please describe the facility and how it was damaged:      
Damaged Components (with common material types). Please select all that apply.
☐ Compressor station
☐ Electrical control panel
☐ Electrical cables
☐ Pipe
☐ Sensor
☐ Supervisory control and data acquisition (SCADA)
☐ Tank
☐ Other. Please describe:      
Power plant, Power transmission and distribution system, Substation, Wind turbine48 
Please describe the facility and how it was damaged:      
Damaged Components (with common material types). Please select all that apply.
☐ Cable 
☐ Conductor
☐ Conduit
☐ Cooling tower
☐ Crossarm 
☐ Electrical panel
☐ Electrical wire
☐ Insulator 
☐ Line
☐ Pole
☐ Riser
☐ Sensor
☐ Supervisory control and data acquisition (SCADA)
☐ Transformer
☐ Tower
☐ Turbine
☐ Other. Please describe:      
Railway, Subway49
Please describe the facility and how it was damaged:      
Damaged Components (with common material types)
☐ Electrical panel
☐ Electrical wire
☐ Elevator
☐ Escalator
☐ Insulator
☐ Lighting
☐ Signal
☐ Switch
☐ Train track
☐ Other. Please describe:         
Reservoir50
Please describe the facility and how it was damaged:      
What is the type of reservoir?
☐ Dry
☐ Off stream
☐ On stream
Does the facility have a spillway?
☐ No
☐ Yes. What is the spillway type?
☐ Controlled
☐ Chute
☐ Ogee
☐ Shaft
☐ Side channel
☐ Siphon
☐ Uncontrolled
☐ Other. Please describe:      
Damaged Components (with common material types). Please select all that apply.
☐ Abutments
☐ Armor 
☐ Rip-rap
☐ Rock armor
☐ Shot rock
☐ Other. Please describe:      
☐ Control gate
☐ Core 
☐ Concrete
☐ Earth
☐ Metal
☐ Plastic
☐ Other. Please describe:      
☐ Electrical panel
☐ Electrical cables
☐ Electrical distribution and control systems
☐ Emergency motor/generator set and transfer switch
☐ Foundation 
☐ Rock
☐ Soil
☐ Other. Please describe:      
☐ Lining 
☐ Outlet gate. Please describe:      
☐ Overflow structure (Spillway)
☐ Sensor
☐ Supervisory control and data acquisition (SCADA)
☐ Vegetative cover
☐ Weir
☐ Other. Please describe:      
Road, Airport Runway/Taxiway, Parking, Sidewalk51
Please describe the facility and how it was damaged:      
Number of lanes:      
Damaged Components (with common mat☐rial types). Please select all that apply.
☐ Surface 
☐ Asphalt
☐ Concrete
☐ Composite
☐ Chip & seal
☐ Dirt
☐ Gravel
☐ Other. Please describe:      
☐ Base 
☐ Dirt
☐ Gravel
☐ Sand
☐ Other. Please describe:       
☐ Subbase 
☐ Asphalt
☐ Concrete
☐ Composite
☐ Chip & seal
☐ Dirt
☐ Gravel
☐ Other. Please describe:      
☐ Curb
☐ Asphalt
☐ Concrete
☐ Other. Please describe:      
☐ Ditch 
☐ Dirt
☐ Gravel
☐ Other. Please describe:       
 
☐ Embankment 
☐ Dirt
☐ Gravel
☐ Sand
☐ Rock 
☐ Other. Please describe:          
☐ Guardrail
☐ Lighting
☐ Median
☐ Shoulder 
☐ Asphalt
☐ Concrete
☐ Composite
☐ Chip & seal
☐ Dirt
☐ Gravel
☐ Other. Please describe:      
☐ Sidewalk/Path
☐ Asphalt
☐ Concrete
☐ Composite
☐ Chip & seal
☐ Dirt
☐ Gravel
☐ Other. Please describe:       
☐ Traffic barrier
☐ Traffic signal
☐ Other. Please describe:      

Water/ Wastewater52
Please describe the facility and how it was damaged:      
Damaged Components (with common material types). Please select all that apply.
☐ Aeration tank
☐ Chlorination system
☐ Clarifier
☐ Effluent outflow
☐ Electrical panel
☐ Electrical cable
☐ Electrical motor/generator set and transfer switch
☐ Filter
☐ Gauge
☐ Generator
☐ Intake system
☐ Pipes
☐ Power source and its distribution and control systems
☐ Primary Sedimentation
☐ Pump
☐ Sensor
☐ Supervisory Control and Data Acquisition (SCADA)
☐ Tank
☐ Other. Please describe:      
Other53
Please describe the facility and how it was damaged:      
Please list the damaged component(s) :      
 Section IV– Component Damage Description and Dimensions54
Complete this section for each damaged component. 
Component: [system generated] 55
Component location: [system generated] 56
Incident Peril(s): [system generated] 57
Cause of facility/component damage: [system generated] 58
Manufacturer’s name plate data:      59
Type, style, model:      60
Material:      61
Quantity:      62 Unit of measure:      
Dimensions: 63 Length:        Width:        Height:      
Make, model, year      64     
Capacity, size, horsepower      65
Additional information:

Section V– Sketch of Site/Facility/Damage/Dimensions66
Use this section to capture sketches, diagrams, or other graphics of damage to the facility and its components.
Aqueduct, Canal, Drainage channel67

Athletic court, Athletic field, Golf course, Tennis court, Playground68


Basin (Debris, Detention, Sediment, Stormwater Retention and Detention) 69









Beach, Dune70


Berm, Levee, Sand Revetment, Seawall71

Boardwalk, Trail72

Bridge73



Building74

Cemetery75

Communications System76

Contents77
N/A
Culvert, Ditch78

Dam79

Dock, Harbor, Pier, or Port80

Equipment and Vehicles81 
N/A
Fish hatchery, Zoo82
N/A
Lift station, Pumping station83

Natural gas transmission and distribution84






Power plant, Power transmission and distribution system, Substation, Wind turbine85

Railway, Subway86








Reservoir87
N/A
Road (Airport runway/taxiway, Parking, Road, Runway, Sidewalk)88

Swimming pool89
 N/A
Water /Wastewater90
N/A
Water control facilities91


Sketch

Notes and comments:      






Section VI – Photographs
Please provide photos of the damage to the facility and components. 92  Please upload as many photos as needed to fully show the extent of the damage.
File name:      93
Damage description:      94
Photo number: [system generated] 95 
Sub-site identifier:      96

Due to the historic nature of the facility, please provide contextual photos of the facility and surroundings: Please upload as many photos as needed to fully show the contextual area, all sides of the exterior (North, South, East, West), and historic aspects of the facility. 97
File name:      98
Photo description:      99
Photo number: [system generated] 100
Sub-site identifier:      
Total number of photos: [system calculated] 101
Section VII– Applicant Review102
Applicant personnel that submitted the damage information      103
Title [system generated]
Signature [system generated]
Date submitted [system automated] 104
Applicant personnel that attended the inspection      
Title [system generated]
Signature [system generated]
Date submitted [system automated] 105
Do you concur with the damage reported?
☐ No. Please provide reason for non-concurrence:         	
☐ Yes   
Section VIII – Recipient Recommendation106
Do you concur with the damage reported?
☐ No. Please provide reason for non-concurrence:      	
☐ Yes
Recipient’s Authorized Representative [system generated]
Title [system generated]
Signature [system generated]
Date submitted [system automated] 107