Form FEMA Form FF-104-F FEMA Form FF-104-F DCM Federal Award Application

Department of Homeland Security

Federal Emergency Management Agency

APPLICATION FOR DISASTER CASE MANAGEMENT

PART 1: GENERAL APPLICATION INFORMATION

Failure to use this application may result in delay or denial of processing the request. This application must be submitted within 90 days of a presidential declaration of a major disaster that includes authorization of Individual Assistance and Disaster Case Management (DCM). The application deadline can only be extended if requested in advance and authorized by FEMA in accordance with the Individual Assistance Program and Policy Guide (IAPPG¹).

1. DCM Funding Request Date:

2. Major Disaster Declaration #:

3. Major Declaration Date with Individual Assistance:

4. Applicant (i.e., State, Tribal, or Territory (STT) Agency Requesting FEMA Funding for DCM):

5. Primary Point of Contact (POC) Information for DCM Application:

   1. POC Name:

   2. Organization:

   3. Organization Mailing Address:

   4. Organization E-mail Address:

   5. Organization Phone Number:

6. Total amount requested for DCM funding (rounded to the nearest dollar): $

7. Disaster designated areas in which services will be provided [if able, include a map]:

8. Requested time period for providing services (period of performance), starting on the date Individual Assistance was included in the major disaster declaration:

PART 2: ASSESSMENT

Activities from the Date of Incident

1. Provide a description of disaster case management activities from the date of the disaster incident to the date of the application.

Resources and Capabilities

2. The DCM program requires available resources outside of the federal government to address survivors’ disaster-caused unmet needs. Provide a list of STT, local government, and voluntary agency resources available for referral to address the disaster-caused unmet needs.

3. How are survivors with disaster-caused unmet needs being referred to agencies with available resources?

4. Provide an explanation as to why the existing STT capabilities, including assistance from local government and voluntary agency partners, cannot meet the disaster-caused needs of the survivors?

5. How is the STT obtaining information about trends in disaster-caused unmet needs and/or working individual cases?

Long-Term Recovery Group Activities

6. Describe the existing or planned Long-Term Recovery Group (LTRG) organizational structure. Include their operational timeline. involved. If there are no existing LTRGs, skip to Population to Serve section.

7. How many LTRGs are established for the disaster, what part of the disaster population are they serving, and what resources/services are they providing to address disaster-caused unmet needs?

8. How do the LTRGs identify cases and do they meet for case presentation and review? If yes, where and how do they receive these cases?

9. Do the LTRGs currently have or intend to hire case managers? If yes, include staffing numbers, current and anticipated service capacity, and onboarding timelines.

Population to Serve

10. How many survivors does the applicant plan to provide DCM services to within the requested period of performance?

11. Include a justification and explanation of how the applicant determined the estimated number of survivors with disaster-caused unmet needs.

PART 3: IMPLEMENTATION

Include attachments if additional room is needed on the following plans:

Service Delivery Plan

1. Provide a brief summary on how the applicant proposes to provide services to supplement existing capabilities to meet the survivors’ disaster-caused unmet needs. Include an overview of the length of time services will be required and describe how long-term cases will be handled.

2. Describe how the applicant will ensure the DCM program is accessible to all eligible individuals, including individuals in underserved communities.

Work Plan

3. Provide an administrative overview/summary of the work plan for program implementation, including milestones for performance/successes and deliverables.

4. Include details on the system/technology to be used to support this program and an overview of the management plan (including administrative controls and supervision), description of identified service providers, and description of plan for sub-recipient/sub-contracting agreements and solicitation.

5. Describe strategies for mobilization, outreach, addressing disaster-caused unmet needs (including tiers for identifying and triaging each need) as well as accessibility of outreach materials and services for underserved populations.

6. List the trainings that will be provided to staff as part of the program, including requirements, timeline, and description.

7. Provide an overview of the plan for program and financial monitoring and quality control, including information on reports that will be provided and how requirements and conditions will be continued to be assessed and met.

8. List milestones and accomplishments to be met before close out of the DCM program, including days before program end date for case closeout or transfer and records management following closeout.

PART 4: ATTACHMENTS (FORMS, BUDGET, NARRATIVE)

Include the following forms and budget items with this application.

1. Standard Form 424: Request for Federal Assistance (SF-424).

This document must be signed by the Governor’s Authorized Representative, Tribal Chief Executive, or Territory Authorized Representative.

2. Standard Form 424a: Budget Information – Non-Construction Programs (SF-424a).

3. Standard Form 424b: Assurances for Non-Construction Programs (SF 424b).

This document must be signed by the Governor’s Authorized Representative, Tribal Chief Executive, or Territory Authorized Representative.

4. Budget Workbook: Budget detailing individual line items at the STT/applicant, management (if applicable), and qualified provider(s) organization level. Cost pools are not allowed, the applicant must show their math).

5. Budget Narrative: Budget Narrative must include a detailed explanation and overview of the staffing, training, supplies, and other programmatic expenses for which funding is being requested. Include what the funding is for, how many people/items are required and why, timelines for the funding, position descriptions for any staff, and a complete breakdown of costs.

6. Organizational Chart (Optional): An organizational chart is optional, however, attaching it may provide a visual to help FEMA understand the geographic distribution of staff and provide additional justification for the requested costs.

PART 5: ACKNOWLEDGEMENT

Standard Lobbying Form (SF-LLL) and the Grants.gov Lobbying Certification Form must be on file with FEMA.

1. Please acknowledge that the STT will comply with the following assurances as referenced in the FEMA-State/Tribe/Territory Agreement and the Department of Homeland Security (DHS) Standard Terms and Conditions (DHS Standard Terms and Conditions | Homeland Security) by checking the following boxes (double click each box):

Lobbying

Drug-Free Workplace

Disbarment, Suspension and Other Responsibility Matters

2. By signing this document, the Governor’s Authorized Representative, Tribal Chief Executive, or Territory Authorized Representative agrees to and/or certifies the following:

The DCM-related requirements are beyond the state, tribe, territory, and local government capabilities.

The program, if approved, will be implemented according to the plan contained in the application approved by the Regional Administrator.

The state, Indian tribal government, or territory will maintain close coordination with and provide required reports, including a Demobilization Plan within 90 days of award, to the Regional Administrator.

3. By signing below, the Governor’s Authorized Representative, Tribal Chief Executive, or the Territory Authorized Representative affirms that the preceding questions have been answered correctly and truthfully to the best of their knowledge.

Authorized Representative’s Signature:

Authorized Representative’s Name (Print): ___________________________________

Authorized Representative’s Title (Print): ____________________________________

Date:

1 Individual Assistance Program and Policy Guide can be found here: Policy, Guidance and Fact Sheets | FEMA.gov