HomeMy WebLinkAboutREQUEST FOR PUBLIC ASSISTANCE FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.No.3067-0151
REQUEST FOR PUBLIC ASSISTANCE Expires Apnl 30,2001
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes. The burden estimate includes time for reviewing instructions,searching existing
data sources,gathering and maintaining the needed data,and completing and submitting the forms. 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 the forms. Send comments regarding the accuracy of the burden
estimate and any suggestions for reducing the burden to:Information Collections Management,Federal Emergency Management Agency,500 C Street,
SW,Washington DC,20472, Paperwork Reduction Project(3067-0151). NOTE: Do not send your completed form to this address.
APPLICANT (Political subdivision or eligible applicant) DATE SUBMITTED
COUNTY (Location of Damages. If located in multiple counties,please indicate.)
APPLICANT PHYSICAL LOCATION
STREET ADDRESS
7, t - 1"r1 u / I e-/2 2 ,, rre -
CITY COUNTY STATE ZIP CODE
iU) Pi.-1 Q-t.e.) c:) 6 k k c:ir .o TLA-1)A.)a 7 c 3
MAILING ADDRESS (If different from Physical Location)
STREET ADDRESS
POST OFFICE BOX CITY STATE ZIP CODE
Primary Contact/Applicant's Authorized Agent Alternate Contact
NAME NAME
TITLE TITLE
•
BUSINESS PHONE •
BUSINESS PHONE
:a ct - oicll — Li 32 i9—c9 I / '" yt 3
FAX NUMBER FAX NUMBER
4 S 7 ir . ''/? -:_ may/- 4.S-7/
HOME PHONE(Optional) HOME PHONE(Optional)
CELL PHONE CELL PHONE
E-MAIL ADDRESS E-MAIL ADDRESS
4.,/e/A C . E Ja! fef &fY7-6-/e4.0 4 1,40-6 ti I/ice:1,05r4,vei
PAGER&PIN NUMBER PAGER&PIN NUMBER
Did you participate in the Federal/State Preliminary Damage Assessment(PDA)? Q Yes ❑ No
Private Non-Profit Organization? ❑ Yes ❑ No
If yes,which of the facilities 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 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.
Offle ai Use Only FEMA.-` r L-'1 - �DR REPLACESF1PS#
��;' �
DaEe Receiv ed
FEMA Form 90-49,SEP 98 ALL PREVIOUS EDITIONS
Q ;s �S � �►�t.vb : F A ( - D R -zA
N fir �iUT S�tic are:P. 57o Fi/o12
t'.. — Pe-2.:n a3i 2 CX57 U G 4 a,
FFi