Form 112-0-10 FEMA GRANTS APPLICATION

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
FEMA GRANTS APPLICATION

O.M.B. No. 1660-0025
Expires XX-XX-XXXX

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 0.75 hours 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 the form. This collection of information is required
to obtain or retain benefits. You are not required to submit 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 the burden to: Information Collections Management, Department of Homeland
Security, Federal Emergency Management Agency, 500 C Street SW, Washington, DC 20472-3100, and Paperwork Reduction Project (1660-0025). NOTE: Do
not send your completed form to this address.

2. Type of Application:*
New

1. Type of Submission:*
Pre-application
Application

Continuation

Changed/Correct Application

Revision

*If Revision, select appropriate letter(s)
*Other (Specify)

3. Date Received:*

4. Applicant Identifier:

5a. Federal Entity Identifier:

5b. Federal Award Identifier:*

State Use Only:
6. Date Received By State:

7. State Application Identifier:

8. Applicant Information:
a. Legal Name:*
b. Employer/Taxpayer Identification Number (EIN/TIN):*

c. State Application Identifier:*

d. Address:
Street 1:*
Street 2:
City:*

County/Parish:

State:*

Province:

Country:*

Zip/Postal Code:*

e. Organizational Unit:

Department Name:

Division:

f. Name and Contact Information of Person to be Contacted on Matters Involving this Application:
Prefix:

First Name:*

Middle Name:

Title:
Telephone Number:*
9. Type of Applicant:
Applicant 1: Select Applicant Type
Applicant 2: Select Applicant Type
Applicant 3: Select Applicant Type
Other (Specify):
FEMA Form 112-0-10, (11/13) DRAFT

Last Name:*

Organizational Affiliation:
Fax Number:

E-mail:*

10. Catalog of Federal Domestic Assistance (CFDA):
Number:
Title:
11. Funding Opportunity:*
Title:

Number:
12. Competition Identification:
Number:

Title:

13. Areas Affected by Projects (Cities, Counties, States, etc.) if more space needed please use continuation sheet:

14. Descriptive Title of Applicants Project:*

15. Congressional Districts of:*
Applicant:

Project:

16. Proposed Project:*
Start Date:

End Date:

17. Estimated Funding ($):*
Federal:

Applicant:

State:

Other:

Local:

Program Income:

Total:
18. Is Application Subject to Review by State Under Executive Order (EO) 12372 Process?:*
a. This application was made available to the State under EO 12372 Process for Review on:
b. Program is Subject to EO 12372, but has not been selected by the State for review.
c. Program is not covered under EO 12372.
19. Is the Applicant Delinquent on Any Federal Debt? (If Yes, Provide an Explanation in Attachment):*

Yes

No

20. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to
comply with any resulting terms if I accept an award. I am aware any false, fictitious or fraudulent statements or claims may
subject me to criminal, civil, or administrative penalties. (US Code, Title 218, Section 1001)*
I Agree
Authorized Representative:
Prefix:

First Name:*

Middle Name:

Title:*
Telephone Number:*
Signature of Authorized Representative:*
FEMA Form 112-0-10, (11/13) DRAFT

Last Name:*

Organizational Affiliation:
Fax Number:

E-mail:*
Date Signed:*

Areas Affected by Projects (continuation sheet):

Applicant Federal Debt Delinquency Explanation:
The following field should contain an explanation if the Applicant organization is delinquent on any Federal Debit. Try to avoid extra
spaces and carriage returns to maximize the availability of space.

FEMA Form 112-0-10, (11/13) DRAFT

INSTRUCTIONS

This form (including the continuation sheet) is required for use as a cover sheet for submission of pre-applications, applications and related information under
discretionary programs. Some of the items are required and some are optional. Required items are identified with an asterisk on the form and are specified in
the instructions below.

Items Number

Entry

1

Type of Submission (Required): Select one type of submission:
• Pre-application
• Application
• Changed/Corrected Application – check if the submission is to change or correct a previously submitted application. Unless requested
by the Agency, do not use this to submit changes after the closing date.

2.

Type of Application (Required): Select one type of application:
• New - an application being submitted for the first time.
• Continuation - an extension for additional funding/budget period for a project with a projected completion date. This can include
renewals.
• Revision - any change in the Federal Government's financial obligation or contingent liability from an existing obligation. If a revision,
enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in the text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (Specify)

3.

Date Received: Leave this field blank, the date will be assigned by the Agency.

4.

Applicant Identifier: Enter the entity identifier assigned by FEMA.

5a.

Federal Entity Identifier: Enter the number assigned to your organization by FEMA, if any.

5b.
6
7
8

Federal Award Identifier: For new applications, leave blank. For a continuation or revision to an an existing award, enter the previously
assigned Federal Award Identifier number. If a changed/corrected application, enter the Federal Identifier in accordance with Agency
instructions.
Date Received by State: Leave this field blank, this date will be assigned by the State (if applicable).
State Application Identifier: Leave this field blank, this identifier will be assigned by the State (if applicable).
Applicant Information: Enter the following:

a.

Legal Name (Required): Enter the legal name of the applicant that will undertake the assistance activity. This is the name that the
organization has registered with the Central Contractor Registry (CCR). Information on registering with CCR may be obtained by visiting
the Grants.gov website.

b.

Employer/Taxpayer Number (EIN/TIN (Required)): Enter the EIN/TIN as assigned by the Internal Revenue Service. If your
organization is not in the US, enter 44-4444444.

c.

Organization DUNS (Required): Enter the organizations DUNS or DUNS+4 number received from Dun and Bradstreet. Information on
obtaining a DUNS number may be obtained by visiting the Grants.gov website.

d.

Address: Enter the complete address as follows: Street Address (Line 1 Required), City (Required), County, State (Required, if country
is US), Province, Country (Required), Zip/Postal Code (Required, if country is US)

e.

Organizational Unit: Enter the name of the primary organizational unit (and Department or Division, (if applicable) that will undertake
the assistance activity (if applicable).

f.

Name and Contact Information of Person to be Contacted on Matters Involving this Application: Organizational affiliation (if
affiliated with an organization other on: Enter the name (First and Last, than the application organization (Required)), Telephone
Number (Required), Fax Number, and E-mail Address of the person to contact on matters related to this application (Required).

9.

Type of Applicant (Required): Select up to three applicant type(s).
A. State Government
B. County Government
D. Special District Government
E. Regional Organization
G. Independent School District
H. Public/State Controlled Institution of Higher
Education
J. Indian/Native American Tribal
K. Indian/Native American Tribally Designated
Government (Other than Federally
Organization
Recognized)
M. Non-profit with 50CS IRS Status
N. Non-profit without 501CS IRS Status
P. Individual
Q. For Profit Organization (Other than Small
Business)
S. Hispanic-serving Institution
T. Historically Black Colleges and Universities
(HBCUs)
V. Alaska Native and Native Hawaiian W. Non-Domestic (non-US) Entity
Serving Institutions

C. City or Township Government
F. US Territory or Possession
I. Indian/Native American Tribal Government
L. Public/Indian Housing Authority
O. Private Institution of Higher Education
R. Small Business
U. Tribally Controlled Colleges and
Universities
X. Other (Specify)

10.

Catalog of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic Assistance Number and Title of the
Program under which assistance is requested, as found in the program announcement (if applicable).

11.

Funding Opportunity Number/Title (Required): Enter the Funding Opportunity Number and Title of the opportunity under which
assistance is requested, as found in the program announcement.

12.

Competition Identification Number/Title: Enter the Competition Identification Number and Title of the competition under which
assistance is requested (if applicable).

13.

Areas Affected by Project: List the areas or entities using the categories (e.g., cities, counties, states, etc.). Use the continuation sheet
to enter additional areas (if needed).

14.

Descriptive Title of Applicant's Project (Required): Enter a brief descriptive title of the project. If appropriate, attach a map showing
the project location (e.g., construction or real property projects). For pre-applications, attach a summary description of the project.

FEMA Form 112-0-10, (11/13) DRAFT

15.

Congressional Districts of (Required): Enter the applicant's Congressional District, and enter the District(s) affected by the program or
project. Enter in the format: 2 characters State Abbreviation - 3 characters District Number (e.g., CA-005 for California 5th District). If all
Congressional Districts in a State are affected, enter "All" for the District Number (e.g., MD-All for all of the Congressional Districts in
Maryland). If nationwide (i.e. all Districts within All States are affected), enter US-All. If the program or project is outside the US, enter
00-000.

16

Proposed Projected Start and End Dates (Required): Enter the proposed start and end date of the project.

17.

Estimated Funding (Required): Enter the amount requested or to be contributed during the first funding/budget period by each
contributor. Value of in-kind contributions should be included on appropriate lines, as applicable. If the action will result in a dollar
change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parentheses.

18.

Is the Application Subject to Review by the State Under Executive Order (EO) 12372 Process? Applicants should contact the State
Single Point of Contact (SPOC) for Federal EO 12372 to determine whether the application is subject to the State intergovernmental
review process. Select the appropriate box. If "a." is selected, enter the date the application was submitted to the State.

19.

Is the Applicant Delinquent on Any Federal Debit (Required)? Select the appropriate box. This question applies to the applicant
organization, not the person who signs as the authorized representative. Categories of debit include: delinquent audit disallowances,
loans and taxes. If yes, please include an explanation on the continuation sheet.

20.

Authorized Representative (Required): To be signed and dated by the authorized representative of the applicant organization. Enter
the name (First and Last (Required)), Title (Required), Telephone number (Required), Fax number, and E-mail Address of the person
authorized to sign for the applicant (Required). A copy of the governing body's authorization for you to sign this application as the official
representative must be on file in the applicant's office.

FEMA Form 112-0-10, (11/13) DRAFT