Form FEMA Form 76-10A FEMA Form 76-10A Obligating documents for Awards/Amendments

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

See Reverse for Instructions and
Paperwork Burden Disclosure

OBLIGATING DOCUMENT FOR AWARDS/AMENDMENTS
1. AGREEMENT NO.

2. AMENDMENT NO.

4. CONTROL NO.

3. TYPE OF ACTION
GRANT

AWARD

5. RECEIPENT NAME AND ADDRESS

6. ISSUING FEMA OFFICE AND ADDRESS

8. NAME OF RECEIPENT PROJECT OFFICER

8A. PHONE NO.

10. EFFECTIVE DATE OF THIS ACTION

11. METHOD OF PAYMENT

O.M.B. No 1660-0025
Expires July 31, 2008

CA

AMENDMENT
7. PAYMENT OFFICE AND ADDRESS

9. NAME OF FEMA PROJECT OFFICER

12. ASISTANCE ARRANGEMENT

HHS, SMARTLINK

COST REIMBURSEMENT

SF 270

COST SHARING

OTHER

OTHER

9A. PHONE NO.

13. PERFORMANCE PERIOD
FROM:

TO:
BUDGET PERIOD:

FROM:

TO:

14. DESCRIPTION OF ACTION
a. (Indicate funding data for awards or financial changes)
PROGRAM
NAME
ABBREVATION

CFDA NO.

ACCOUNTING DATA
(ACCS CODE)
XXXX-XXX-XXXXXX-XXXXX-XXXX-XXXX-X

PRIOR
TOTAL
AWARD

AMOUNT
AWARDED
THIS ACTION
+ or (-)

CURRENT
TOTAL
AWARD

CUMULATIVE
NON-FEDERAL
COMMITMENT

TOTALS
b. To describe changes other than funding data or financial changes, attach schedule and check here
15a. FOR NON-DISASTER PROGRAMS: RECEIPENT IS REQUIRED TO SIGN AND RETURN THREE (3) COPIES OF THIS DOCUMENT TO FEMA (See Block 7 for address)

YES

NO

15B. FOR DISASTER PROGRAMS: RECEIPIENT IS NOT REQUIRED TO SIGN
This assistance is subject to the terms and conditions attached to this award notice or incorporated by reference in program legislation or regulation cited above.
16. RECEIPIENT SIGNATORY OFFICIAL (Name and Title)

16a. DATE

17. FEMA SIGNATORY OFFICIAL (Name and Title)

17a. DATE

FEMA Form 76-10A, OCT 04

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1.2 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed
data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden
estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, S.W.; Washington, D.C. 20472 and
Paperwork Reduction Project (1660-0025). NOTE: Do not send your completed form to this address.
INSTRUCTIONS
1.

Enter the agreement number.

2.

Enter the amendment number, if applicable.

3.

Type of Action. Check the appropriate box.

4.

Enter the control number. This number may come from FF 40-1 or it may be an internal control number.

5.

Enter the name and address of the recipient.

6.

Enter the FEMA office and address issuing the award.

7.

Enter the FEMA office and address that will make the payment.

8.

Enter the name and telephone number of the individual at the recipient organization who will be primarily responsible for providing information on the award.

9.

Enter the name and telephone number if the individual at FEMA who will be primarily responsible for providing information o the award.

10.

Enter the effective date of the award.

11.

Check the appropriate box.

12.

Check the appropriate box.

13.

PERFORMANCE PERIOD:
BUDGET PERIOD.

Enter the period of performance for the assistance agreement.

Enter the budget period of the assistance agreement. This may be different than the period of performance.

14.

DESCRIPTION OF ACTION.
PROGRAM NAME ACRONYM. Enter the acronym of the program being funded.
CFDA NO. Enter the corresponding Catalog of Federal Domestic Assistance number.
ACCOUNTING DATA. Enter the accounting code.
PRIOR TOTAL AWARD. This column should be blank on the initial award. On subsequent amendments, it must reflect the amount under "Current Total Award" of the previous Grant/Cooperative
Agreement Award for the specified fiscal year.
AMOUNT AWARDED THIS ACTION (+ or -). This column is used to record the initial award to the State or amendment amount, either increasing or decreasing funds. For decreases, the amount will
Be indicated in brackets ().
CUMULATIVE NON-FEDERAL COMMITMENT. This column records the sum of all non-Federal amounts committed to the efforts to fulfill Federal matching requirements and including commitments
Beyond the required match. The non-Federal matching amounts expressed may be allowable monetary or ink-kind contributions valued in dollars.

14b.

If additional space is needed to describe changes other than funding data or financial change, attach a schedule and check the box.

15a.

Check appropriate box.

15b.

For disaster programs, the recipient is not required to sign the FEMA Form 76-10A