Request for Public Assistance

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RECIPIENT INCIDENT INFORMATION
Paperwork Burden Disclosure Notice
Public reporting burden for this data collection is estimated to average 5 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
FEMA Public Assistance Recipients complete this for each declared incident in Grants Portal to provide incident-specific information and to elect whether to lead all or part of the Public Assistance Program delivery process. 
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: 
    • Incident-level information
    • State-Led Operational Agreement
    • Application for Federal Assistance (SF-424) 
    • Budget Information for Non-Construction Programs (SF-424A) 
    • Assurances for Non-Construction Programs (SF-424B) 
    • Budget Information for Construction Programs (SF-424C)
    • Assurances for Construction Programs (SF-424D) 
    • Disclosure of Lobbying Activities (SF-LLL) 
    • Amendment to the State/Tribe/Territory Annual Administrative Plan
Section I – Declaration Information1
Declaration # Please select one.
Declaration date [system generated]
Recipient 
[system generated]
Region 
[system generated]
For emergency protective measures that involve facility construction or repairs, has a State or Federal agency issued an Emergency Exemption for repair work associated with this incident?
☐ No
☐ Yes
Section II – Recipient-Led Public Assistance
Does the Recipient elect to lead all or part of the delivery of Public Assistance for this declaration?
☒ No. Please provide the reason the Recipient does not elect to lead the delivery of Public Assistance.
☐ Insufficient experience with delivering the Public Assistance program 
☐ Insufficient personnel and resources 
☐ Incident’s characteristics. Please describe:      
☐ Other reason. Please describe:      
☐ Yes. Please upload the Recipient-Led Operational Agreement Addendum2 and select one option for each responsibility. 
Provide customer service/program delivery             		☐ Shared 	☐ Recipient     ☐ FEMA
Perform site inspections 					☐ Shared 	☐ Recipient     ☐ FEMA
Develop project scopes and cost 		            	☐ Shared 	☐ Recipient     ☐ FEMA
Develop Public Assistance mitigation scopes and cost 	☐ Shared 	☐ Recipient     ☐ FEMA
Draft determination memos 					☐ Shared 	☐ Recipient     ☐ FEMA 

Has the Recipient activated a Host-State/Tribe sheltering agreement? 3
☐ No
☐ Yes4
Operations Information
Direct Application Project Reviews5     
☐ Application routes directly to Consolidated Resource Center   
 ☐ Application routes through Recipient

Closeout Request Notification
☐ Allow the Subrecipient to notify the Recipient through FEMA’s grants management software
☐ Disallow the Subrecipient to notify the Recipient through FEMA’s grants management software

Small Project Net Cost Overrun Notification
☐ Allow the Subrecipient to notify the Recipient through FEMA’s grants management software
☐ Disallow the Subrecipient to notify the Recipient through FEMA’s grants management software

Quarterly Progress Report Notification 
☐ Allow FEMA’s grants management software to notify and collect Subrecipients QPR updates
☐ Disallow FEMA’s grants management software to notify and collect Subrecipients QPR updates

Time Extension Report Notification 
☐ Allow FEMA’s grants management software to notify and collect Subrecipients time extension requests 
☐ Disallow FEMA’s grants management software to notify and collect Subrecipients time extension requests

Section IV – Documentation
Documentation. Please upload the following to the Recipient Profile: 
☐ Application for Federal Assistance (SF-424) 6  
☐ Budget Information for Non-Construction Programs (SF-424A) 
☐ Assurances for Non-Construction Programs (SF-424B) 
☐ Budget Information for Construction Programs (SF-424C)
☐ Assurances for Construction Programs (SF-424D) 
☐ Disclosure of Lobbying Activities (SF-LLL) 
☐ Amendment to the State/Tribe/Territory Annual Administrative Plan