Form FEMA Form 90-58 FEMA Form 90-58 Request for Fire Management Assistance Declaration

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION

O.M.B. No. 1660-0058
Expries July 31, 2008

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average1 hour per resposne. 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. Your response is required to obtain or retain Federal assistance through FEMA's Fire Management Assistance
Grant Program. You are not required to respond to this collection of information unless a vaild OMB control number appears in the upper right corner of this form. 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, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0058). NOTE: Do not send your completed survey to the above address.
1. STATE

2. DATE OF REQUEST

3. TIME OF REQUEST

4. NAME OF GOVERNOR OR AUTHORIZED REPRESENTATIVE

PHONE NO. INCLUDING AREA CODE
a. Day
ADDRESS (Street, City, Zip)

5. AGENCY REPRESENTED

b. Night

NOTE: In making this request, the Government agrees to abide by provisions contained in FEMA-State Agreement for Fire Management Assistance under Section 420, PI
93-288 as amended. This request must be signed below by the Governor personally or by his authorized representative, whom he has preveiously authorized to sign this
request in the FEMA - State Agreement.
6. SIGNATURE

TITLE

DATE

I. EXISTING CONDITIONS
7.
EXISTENCE OF
HIGH
FIRE DANGER
CONDITIONS

a. TEMPERATURE

b. RELATIVE HUMIDITY

c. DIRECTION AND VELOCITY OF WIND

d. PREVALING WEATHER CONDITIONS AND PREDICTIONS FOR NEXT 24 HOURS

8. NUMBER OF WILD FIRES
a. CONTROLLED

ACRES BURNED

b. UNCONTROLLED

ACRES BURNED

c. EXISTENCE OF OTHER FIRES NEARBY WHICH LIMITS THE COMMITMENT OF STATE FRIE FIGHTING RESOURCES #
d. EXISTENCE OF OTHER FIRES NEARBY THAT MAY RESULT IN A CONFLAGRATION #
9. INDICES:

10. STATE & LOCAL
NATIONAL FIRE DANGER RATING SYSTEM
OTHER (KBDI, SPI, HAINES, PALMER, ETC.)

BURN BANS:

YES

NO

YES

NO

11. NATIONAL
WATCHES:

WARNINGS

YES

NO

II. FIRE SITUATION REPORT
12. TIME OF REPORT

13. NAME OF UNCONTROLLED FIRE

15. LOCATION OF UNCONTROLLED FIRE: (County)

14. DATE
16. ACRES BURNING:
a. FEDERAL

%

b. STATE

17. MANPOWER AND RESOURCES COMMITTED (Attach seperate sheet if necessary)
STATE:

LOCAL:

18. TYPE AND AMOUNT OF FEDERAL OR OTHER ASSETS & RESOURCES NEEDED: (FEMA does not order resources)

FEMA Form 90-58, JUL 05

REPLACES ALL PREVIOUS EDITIONS

%

c. PRIVATE

%

III. CURRENT THREAT
19. THREAT TO LIFE:

a. PREPARATIONS MADE FOR EVACUATION?
YES

#

b. PERSONS EVACUATED:

NO

#

ADDITIONAL INFORMATION

20. NAME AND LOCATION OF COMMUNITY THREATENED
CITY

CITY
SUBDIVISION

21. CASUALTIES:

22. THREAT TO PRIVATE PROPERTY: (Dwellings)

1. CIVILIAN LOSS OF LIFE

1. NUMBER OF HOMES

2. CIVILIANS INJURED
3. FIRE FIGHTERS LOSS OF LIFE

a. % OF PRIMARY

b. % OF SECONDARY

4. FIRE FIGHTERS INJURED
23. THREAT TO FACILITIES (Include number when applicable)

AMOUNT

TYPE

AMOUNT

BUILDINGS

RECREATION

ROADS & BRIDGES

EQUIPMENT

INFASTRUCTURE

BUSINESS

UTILITIES

OTHER

ADDITIONAL INFORMATION

24. THREAT TO RESOURCES
WATERSHED

WILDLIFE (Type threatened, fur-bearing animals, big game, etc.)

IIRRIGATION

ENVIRONMENTAL RESOURCES (bio-diverse areas, etc.)

FLOOD CONTROL

CULTURAL RESOURCES

FISHING STREAMS & SPAWING SITES

ECONOMIC INJURY

ADDITIONAL INFORMATION

IV. STATE ASSESSMENT
25. EMERGENCY MANAGEMENT ASSESSMENT OF THE SITUATION

DATE

SIGNATURE
26. FORESTRY ASSESSMENT OF THE SITUATION

SIGNATURE

DATE

FOR FEMA REGIONAL USE ONLY
SIGNATURE

TITLE

DATE

TYPE