Form FEMA Form FF-104-F FEMA Form FF-104-F LOCAL GOVERNMENT RESOLUTION - COLLATERAL SECURITY

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
LOCAL GOVERNMENT RESOLUTION - COLLATERAL SECURITY

OMB Control Number: 1660-0083
Expiration: 8/31/2023

RESOLUTION
OF

BE IT RESOLVED BY
(Governing Body)

(Public Entity)

THAT we pledge the following listed collateral security to the Federal Emergency Management Agency (FEMA) on the
Promissory Note for a Community Disaster Loan for $
,
pursuant to Section 417 of the
executed on
20
Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288, as amended, and FEMA Regulation,
44 CFR 206,
Subpart K. We further understand that failure to repay any outstanding principal and related interest on those portions of the loan which do
not qualify for loan cancellation as determined by FEMA or any successor agency will result in forfeiture of as much as the listed collateral
security as is necessary to collect such outstanding principal and interest. (List the collateral security below. Use additional sheets if
needed.)

Passed and approved this

day of

, 20

.

(Name and Title)
(Name and Title)
(Name and Title)
CERTIFICATION
I,

, duly appointed and

of

(Title)
, do hereby certify that the above is a true and correct copy of a
resolution passed and approved by the

of
(Public Entity)
,
.
20

(Governing Body)
day of

on the
DATED:

(Official Position)

(Signature)

[SEAL]
FEMA Form 085-0-1 (11/17)

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RECORDED
,

I,

, a responsible and
(Title)

(Name)

, do hereby attest that the

authorized official of
(Public Entity)
Collateral Security Resolution which accompanies this form has been duly recorded at
(Indicate where Recorded)
The Collateral Security Resolution was recorded on the

day of

, 20

.

DATED:

(Official Position)

(Signature)

[SEAL]

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 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 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 (1660-0083). NOTE: Do not send your completed form to the above address.

FEMA Form 085-0-1 (11/17)

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