FEMA Form FF-104-F Request for Presidential Disaster Declaration Major Disa

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
REQUEST FOR PRESIDENTIAL DISASTER DECLARATION
MAJOR DISASTER OR EMERGENCY

OMB Control Number 1660-0009
Expires 03/31/2016
1. Request Date

Burden Disclosure Notice
Public reporting burden for this form is estimated to average 9 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 a benefit. 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 the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency
Management Agency, 500 C Street SW, Washington, DC 20472, Paperwork Reduction Project (1660-0009). NOTE: Do not send
your completed form to this address.
Completion of this form including applicable attachments satisfies legal requirements for emergency and major disaster declaration
requests under 42 U.S.C. §§ 5170 and 5191, respectively, as implemented at 44 C.F.R.. §§ 206.35 and 206.36. Failure to use this
form may result in a failure to meet these requirements and/or a delay in processing the request.
2a. Name of State (as defined in Stafford Act 102, 42 U.S.C. § 5122) or Indian
tribal government requesting declaration.

2b. Population (as reported by
2010 Census) or estimated
population of Indian tribal
government's damaged area(s).

DRAFT

3. Governor's or Tribal Chief Executive's
Name

4. Designation of State or Tribal Coordinating Officer upon declaration (if available)
and phone number

5. Designation of Governor's Authorized Representative or Tribal Chief Executive Representative upon declaration (if available) and
phone number
6. Declaration Request For:

7. Incident Period:

Major Disaster (Stafford Act Sec.
401)

Beginning Date

End Date

or

Emergency (Stafford Act Sec. 501
(a))

If requesting a "continuing" incident period, enclose an
official statement from a qualified Federal Government
agency acknowledged as a national authority in a specific
Continuing
incident field (e.g., United States Geological Survey for
seismic incidents, the National Weather Service for
flooding).

7b. Type of Incident (Check all that apply)
Drought

Earthquake

Explosion

Fire

Flood

Hurricane

Landslide

Mudslide

Severe Storm
(rain, high water, wind-driven, rain, hail,
lightning)
Tidal Wave

Tornado

Snowstorm
Straight-Line Winds
(Must include Enclosure D: Historic and Current Snowfall
Data)
Tsunami
Volcanic Eruption
Winter Storm
Tropical Storm
Tropical Depression

Other (please specify)
8. Description of damages (Short description of impacts of disaster on affected area and population). Include additional details in
enclosed Governor's or Tribal Chief Executive's cover letter.

9. Description of the nature and amount of State and local or Indian tribal government resources which have been or will be
committed. Include additional details in enclosed Governor's or Tribal Chief Executive's cover letter.

FEMA Form 010-0-13, (3/15)

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10. Joint Preliminary Damage Assessment*
Individual Assistance

Dates Performed Requested

Start

End

Individual Assistance Accessibility Problems (Areas that could not be accessed, and why)

Public Assistance

Dates Performed Requested

Start

End

Public Assistance Accessibility Problems (Areas that could not be accessed, and why)

DRAFT
11. Programs and Areas Requested
Individual Assistance
All

N/A

Individuals and Households
Program

Disaster Case Management

Crisis Counseling Program

Disaster Legal Services

Disaster Unemployment
Assistance

Small Business Administration (SBA) Disaster
Assistance

For the following jurisdictions, specify programs and areas (counties, parishes, independent cities; for Indian tribal government, list
tribe(s) and/or tribal area(s)) If additional space is needed, please enclose additional documentation).

For States, identify Federally-recognized Tribes in the requested counties (if applicable).

Please see Enclosure A: Supplemental Information for Individual Assistance for additional information in support of this request*.
*Not Required for Emergency Declaration Request
FEMA Form 010-0-13, (3/15)

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11. Programs and Areas Requested (Continued)
Public Assistance

N/A

Debris Removal (Category A)

Emergency Protective
Measures (Category B)

Permanent Work (Categories C-G)*
(not available for Emergency
Declaration Requests)

For the following jurisdictions, specify programs and areas (counties, parishes, independent cities; for Indian tribal government, list
tribe(s) and/or tribal area(s)). If additional space is needed or your request includes different categories of work for different
jurisdictions; please enclose additional documentation.

For States, identify Federally-recognized Tribes included in the requested counties (if applicable).

Please see Enclosure B: Supplemental Information for Public Assistance for additional information in support of this request*.

DRAFT
Indemnification for Debris Removal Activity

I do not anticipate the need for debris removal.

I anticipate the need for debris removal, which poses an immediate threat to lives, public health and safety. Pursuant to Sections
403 and 407 of the Stafford Act, 42 U.S.C. §§ 5170b & 5173, the State or Indian tribal government agrees to indemnify and hold
harmless the United States of America for any claims arising from the removal of debris or wreckage for this disaster. The State or
Indian tribal government agrees that debris removal from public and private property will not occur until the landowner signs an
unconditional authorization for the removal of debris.
Request for Direct Federal Assistance
I do not request direct Federal assistance at this time.
I request direct Federal assistance for work and services to save lives and protect property,
and:
a. I request the following type(s) of assistance:

b. List of reasons why State and local or Indian tribal government cannot perform, or contract for, required work and services.

c. In accordance with 44 C.F.R. § 206.208, the State or Indian tribal government agrees that it will, with respect to direct Federal
assistance: (1) Provide without cost to the United States all lands, easements, and rights-of-ways necessary to accomplish the
approved work; (2) Hold and save the United States free from damages due to the requested work, and shall indemnify the Federal
Government against any claims arising from such work; (3) Provide reimbursement to FEMA for the non-Federal share of the cost of
such work in accordance with the provisions of the FEMA-State or FEMA-Tribe Agreement ; and (4) Assist the performing Federal
agency in all support and local jurisdictional matters.
Request for Snow Assistance

N/A

I request snow assistance.

Snow assistance for the following jurisdictions (Specify counties, independent cities or tribes and/or tribal areas).

Please see Enclosure D: Historic and Current Snowfall Data for additional information in support of this request*.
*Not Required for Emergency Declaration Request
FEMA Form 010-0-13, (3/15)

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11. Programs and Areas Requested (Continued)
Hazard Mitigation*

OR

Statewide

For the following specific counties, parishes, independent cities or tribes and/or tribal areas.

12. Mitigation Plan Information*
b. Type of Plan

a. Mitigation Plan Expiration Date

Enhanced

Standard

13. Other Federal Agency Programs

DRAFT

I do not anticipate requirements from Other Federal
Agencies

I do anticipate requirements from Other Federal
Agencies

Please see Enclosure C: Requirements for Other Federal Agency Programs for additional information in support of this request*.
14. Findings and Certifications

I certify the following:

a. I have determined that this incident is of such severity and magnitude that effective response is beyond the capabilities of the
State and the affected local government or Indian tribal government and that supplementary federal assistance is necessary.
b. In response to this incident, I have taken appropriate action under State or tribal law and have directed the execution of the State
or Tribal Emergency Plan on
in accordance with the Stafford Act.
c. The State and local governments, or Indian tribal government will assume all applicable non-Federal share of costs required by
the Stafford Act.
15. List of Enclosures and Supporting Documentation
Cover Letter

Enclosure A (Individual Assistance)*

Enclosure C (Requirements for Other Federal Agency Programs)

Enclosure B (Public Assistance)*
Enclosure D (Historic and Current Snowfall Data)

Additional Supporting Documentation

Governor's or Tribal Chief Executive's Signature

Date

If anyone except the Governor or Tribal Chief Executive signs this document, please provide the documentation that establishes that
this individual has the legal authority to act on behalf of the Governor or Tribal Chief Executive.

*Not Required for Emergency Declaration Request
FEMA Form 010-0-13, (3/15)

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