FEMA Form FF-104-F Request for Public Assistance

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
REQUEST FOR PUBLIC ASSISTANCE

OMB Control Number 1660-0017
Expires November 30, 2023

Paperwork Burden Disclosure Notice
Public reporting burden for this data collection is estimated to average 15 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
Authority: FEMA is authorized to collect the information requested pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§
402-403, 406-407. 417, 423, and 427, 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e; The American Recovery and Reinvestment Act of 2009,
Public Law No. 111-5, § 601; and “Public Assistance Project Administration,” 44 C.F.R. §§ 206.202, and 206.209.
APPLICANT (Political subdivision or eligible applicant)

DATE SUBMITTED

COUNTY (Location of Damages. If located in multiple counties, please indicate)
APPLICANT PHYSICAL LOCATION
STREET ADDRESS
CITY

COUNTY

ZIP CODE

STATE

MAILING ADDRESS (If different from Physical Location)
STREET ADDRESS
POST OFFICE BOX

CITY

STATE

Primary Contact/Applicant's Authorized Agent

Alternate Contact

NAME

NAME

TITLE

TITLE

BUSINESS PHONE

BUSINESS PHONE

FAX NUMBER

FAX NUMBER

HOME PHONE (Optional)

HOME PHONE (Optional)

CELL PHONE

CELL PHONE

E-MAIL ADDRESS

E-MAIL ADDRESS

PAGER & PIN NUMBER

PAGER & PIN NUMBER

Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?
Private Non-Profit Organization?

YES

ZIP CODE

YES

NO

NO

If yes, which of the facilities identified below best describe your organization?
Title 44 CFR, part 206.221(e) defines an eligible private non-profit facility as: "... any private non-profit educational, utility, emergency, medical or
custodial care facility, including a facility for the aged or disabled, and other facility providing essential governmental type services to the general public,
and such facilities on Indian reservations." "Other essential governmental service facility means museums, zoos, community centers, libraries,
homeless shelters, senior citizen centers, rehabilitation facilities, shelter workshops and facilities which provide health and safety safety services of a
governmental nature. All such facilities must be open to the general public."
Private Non-Profit Organizations must attach copies of their Tax Exemption Certificate and Organization Charter or By-Laws. If your
organization is a school or educational facility, please attach information on accreditation or certification.
OFFICIAL USE ONLY: FEMA -

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FEMA Form FF-104-FY-21-131 (formerly 009-0-49)
(5/21)

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FIPS#

DATE RECEIVED