FEMA Daily Fact Sheet Template

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Submission Request for Building Resilient Infrastructure and Communities Direct Technical Assistance (BRIC DTA)
This is a submission request for non-financial direct technical assistance offered through the Federal Emergency Management Agency’s (FEMA’s) Building Resilient Infrastructure and Communities (BRIC) program. Please complete all required sections and submit via email to [email protected] by XXX, XX, 2025, 3 p.m. ET. 
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of the purposes for which the Federal Emergency Management Agency (FEMA) is requesting the information on this form. 
AUTHORITY: 
FEMA is authorized to collect the information requested on this form pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Pub. L. 93-288, as amended), 42 U.S.C. §§ 5121-5207; and National Flood Insurance Act of 1968 (“NFIA”), as amended, and the Flood Disaster Protection Act of 1973, as amended (42 U.S.C. § 4001, et. seq.).
PURPOSE(S):
FEMA is requesting this information to support its administration and evaluation of grant applications submitted under its Public Assistance (PA), Hazard Mitigation Assistance (HMA), and other disaster grants and disaster loan programs developed to mitigate and recover from emergencies and disasters. 
ROUTINE USE(S)
The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/ALL – 004 General Information Technology Access Account Records System of Records, 77 Fed. Reg. 70792, (Nov. 27, 2012); DHS/FEMA-004 Non-Disaster Grant Management Information Files, 87 Fed. Reg. 41141, (July 11, 2022); DHS/FEMA-009 Hazard Mitigation Disaster Public Assistance and Disaster Loan Programs, 79 Fed. Reg. 16015, (Mar. 24, 2014);  and upon written request, by agreement, or as required by law. The Department of Homeland Security’s Systems of Records notices may be found at https://www.dhs.gov/system-records-notices-sorns.
DISCLOSURE
Providing this information to FEMA is voluntary. However, failure to provide this information may prevent your eligibility to receive funding from covered PA or HMA grant programs.  


               State or Local Community/Tribal Nation/Territory Details (*Required)
Requestor Name: 
(Name of community, Tribal Nation or territory requesting assistance. E.g.: City of Selma)
State/Tribal Nations/Territory:
(Physical geographic location. E.g.: Alabama)
Jurisdiction Type (check one):
(Common name for the area that has defined political boundaries. E.g.: City)
__City  __ Town/Township  __Parish  __Borough  __County  __Special District Government  __Tribal
Tribal Status (check one): 
(Tribal government ONLY)
 __Federally Recognized
 __Non-Federally Recognized 
Benefiting Area:
(Name of area, location, or Tribal Nation intended to receive or benefit from the technical assistance. E.g.: City of Selma)
Benefiting Area Zip Code: 
(Zip code of area, location, or Tribal Nation intended to receive or benefit from the technical assistance. E.g.: 36701)
Benefiting Area County:
(County of area, location, or Tribal Nation intended to receive or benefit from the technical assistance. E.g.: Dallas County)
               Community Points of Contact (POCs) (*Required)
Please provide the following information for two (2) POCs and indicate if the POC has signing authority on behalf of the community, Tribal Nation, or territory. 
Primary POC Name: 
Primary POC Phone Number: 
Primary POC Email Address:
Secondary POC Name: 
Secondary POC Phone Number: 
Secondary POC Email Address:



Does the POC(s) have signing authority?
(Signing authority refers to the authority given to a person to sign documents on behalf of the authorizing organization. Check all that apply.)
__ Primary POC
__ Secondary POC
__ None
               BRIC DTA Request (*Required)
    1. Please select a PRIMARY BRIC DTA request (check one):
(Select the BRIC DTA request indicating your main technical assistance need.)
__Hazard Mitigation Plan Development/Updates
__Risk Assessments
__Community Outreach and Partnership Development
__General Hazard Mitigation Capacity Building Workshops
__Project Identification and Scoping
__Potential Funding Sources Identification 
__Benefit-Cost Analysis (BCA)
__Grant Writing Assistance or Workshop
__Grant Management Assistance or Workshop
__Other: _______________________
    2. Please select a PRIMARY natural hazard associated with the request (check one):
(A natural hazard is an environmental phenomenon that has the potential to impact lives and livelihood.)
__ Drought
__ Earthquake
__ Extreme Temperature
__ Fire
__ Flooding
__ Infrastructure Failure
__ Landslide/Debris Flow
__ Severe Storm
__ Tornado
__ Tropical Cyclone (Typhoon/Hurricane)
__ Other: _______________________
    3. Please select a SECONDARY natural hazard associated with the request (check one): 
(A secondary hazard is an event led or caused by the primary hazard.)
__ Drought
__ Earthquake
__ Extreme Temperature
__ Fire
__ Flooding
__ Infrastructure Failure
__ Landslide/Debris Flow
__ Severe Storm
__ Tornado
__ Tropical Cyclone (Typhoon/Hurricane)
__ Other: _______________________
    4. Please provide a brief description (5–7 sentences) of the PRIMARY BRIC DTA need selected above.
    5. Please provide a brief description (5–7 sentences) of the population(s) that will benefit from BRIC DTA. 
               Other Hazard Mitigation Requests (*Optional)
Is your community, Tribal Nation, or territory currently applying or receiving any FEMA Hazard Mitigation Assistance (HMA) funding this year? 
__ Building Resilient Infrastructure and Communities (BRIC) 
__ Flood Mitigation Assistance (FMA)
__ Hazard Mitigation Grant Program (HMGP)

__ Other: _______________________
__ None
               Acknowledgement (*Required) 
__ On behalf of the requesting community, Tribal Nation, or territory, I confirm the understanding that this request is for non-financial direct technical assistance offered through the BRIC program, and if selected, this community, Tribal Nation, or territory agrees to: a) sign an MOU with FEMA before support begins, and b) actively participate in BRIC DTA according to a BRIC DTA Plan developed in conjunction with FEMA.