FF-104-FY-21-195 ( Commercial Park Unit Pad Requirements – Information Chec

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
COMMERCIAL PARK UNIT PAD REQUIREMENTS - INFORMATION CHECKLIST

OMB Control #: 1660-0138
Expiration: MM/DD/YYYY

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes 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.
This collection of information is mandatory. You are not required to respond to this collection of information unless a valid 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 (1660-0138). Please do not send your completed form to the above
address.
PRIVACY ACT STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part
206.117.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of advising property owners of commercial parks of the
pad requirements for the installation of transportable temporary housing units (TTHUs) as a part of FEMA's direct temporary housing
assistance under a Presidentially-declared disaster.
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/FEMA - 008 Disaster
Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by
law.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent the individual from receiving the requested disaster-related temporary housing assistance.
Site Address: (Park Name, Street, City, State, Zip code, Temp. Housing Property Manager Contact Information:
Unit Pad Number(s). Attach map and detailed directions if rural route).

Description of Pad Premises:

DRAFT

Number of Available Pads
(placed in column)

Number of Feasible Available
Pads (placed in column)

Room for Expansion?
(placed in column)

YES
NO

Pad Size:
3 BDR

3 BDR Accessible

2 BDR

2 BDR Accessible

1 BDR

1 BDR Accessible

Pets Allowed

Utilities

Background Check Required

Rent Amount

Amps

Credit Check Required

Split Lot

School Bus Routes

Other

Wrap Around Services

ADA Accessible Mailboxes
ADA Accessible Dumpsters
Within reasonable commuting distance
FEMA FORM FF-104-FY-21-195 (formerly 009-0-137)
(12/21)

ADA Accessible egress (pathway to unit)
1 BDR Accessible
Accessible Playground area (and path)
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COMMERCIAL PARK UNIT PAD REQUIREMENTS - INFORMATION CHECKLIST continued
Requirements:

Yes

No

Unknown

Does your facility have the ability to provide and maintain all water, sanitary sewage, electrical, other
utilities connections provided on the site at the time of execution of the lease?
Will the facility have the ability to maintain the Pad and premises in good repair during the term of the
lease?
The Property Manager shall not discriminate against any of the Lessee's tenants or prospective
tenants on the basis of race, color, religion, nationality, sex, age, disability, English proficiency, or
economic status.
Manufactured Housing Units (MHUs)
Recreational Vehicles:
UFAS MHUs

Certify:
I certify that this information is true and correct and understand that this document in no way guarantees a lease with FEMA until approved and
authorized by the contracting officer.
Name of Park/ Property Management Representative:

Signature and Title

Date

Name of FEMA Representative

Signature

Date

DRAFT

FEMA FORM FF-104-FY-21-195 (formerly 009-0-137)
(12/21)

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