FEMA Form FF-104-F Request for Public Assistance

DRAFT

DEPARTMENT OF HOMELAND SECURITY OMB Control Number 1660-0017

Federal Emergency Management Agency Expires Month Day, Year

REQUEST FOR PUBLIC ASSISTANCE

Paperwork Burden Disclosure Notice Public reporting burden for this data collection is estimated to average 7 minutes 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 this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. 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 (1660-0017) NOTE: Do not send your completed form to this address.
Privacy Act Statement The collection of this information is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 402-403, 406-407, 417, 423, 427, 428, 502, and 705; 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e, 5189f, 5192, 5205; Title 44 Code of Federal Regulations (C.F.R.) § 206 Subpart G; and 2 C.F.R. § 200. This information is collected to provide assistance to eligible jurisdictions and organizations to facilitate the response to and recovery from a Presidentially-declared disaster or emergency, or to provide assistance for hazard mitigation measures during the recovery process. The disclosure of information on this form is voluntary; however, failure to provide the requested information may delay or prevent the agency from receiving funds from FEMA’s Public Assistance program.
Purpose and Applicability Government entities and Private Nonprofit organizations complete this form to register for FEMA’s Public Assistance program. The Recipient and FEMA use this information to determine whether the Applicant is eligible for Public Assistance and the level of resources required to assist the Applicant. FEMA does not use this information to determine the level of funding it provides. For more information, please see Chapter 3 Applicant Coordination and Eligibility in the Public Assistance Program and Policy Guide or contact the State, local, Tribal, or Territorial emergency management office for additional information. This information is time sensitive. Applicants and Recipients must complete this information within 30 days of the date of declaration or the respective area being designated in the declaration. Applicants not able to submit the information within the allotted time may request a time extension describing the extenuating circumstances. Recipients and Applicants should use PA Grants Portal to submit all documentation and information to FEMA. Questions are displayed in an intuitive manner to show the information and documentation needed based on answers provided. All signatures are official and legally binding. The following information is needed to complete this form: Applicant-level information Impact information Impacted community information Estimated cost Additionally, Private Nonprofit organizations will also need to provide: Nonprofit documentation, including tax exempt status Impacted facility information, including services provided by the impacted facilities Facility ownership and legal responsibility documentation Small Business Administration loan documentation, if applicable
Section I – Declaration Information1
Declaration # Please select one.		Declaration Date [system generated]	Recipient [system generated]	Region [system generated]
Section II – Applicant Information2
Legal name [system generated]			FEMA PA ID [system generated]
Physical address3 [system generated]			Mailing address [system generated]4
How much funding does the Applicant expect to request from FEMA as a result of the disaster? Please select one. ☐ Less than $1,000,000 ☐ Equal to or more than $1,000,000 (Optional) How much experience does the organization’s current staff have with FEMA’s Public Assistance program? Please select one. ☐ The staff has recent experience with FEMA’s Public Assistance Program. Is the Applicant comfortable with proceeding through the Public Assistance process without a FEMA Program Delivery Manager but with access to technical assistance as needed? ☐ No. Please describe:       ☐ Yes ☐ It has been several years since the Applicant has had experience with FEMA’s Public Assistance Program OR the staff that were involved are no longer with the Applicant. ☐ The Applicant has never had experience with FEMA’s Public Assistance Program. ☐ Other. Please describe:       (Optional) Does the Applicant want assistance identifying ways to increase their community’s resiliency by incorporating mitigation into their damaged facilities?5 ☐ No. Please describe:       ☐ Yes (Optional) Does the Applicant have sufficient technology resources to utilize FEMA’s Grants Portal? 6 ☐ No. Please describe technology resource issue(s):       ☐ Yes Did a representative attend an Applicant Briefing? 7 ☐ No.8 ☐ Yes
Section III – Private Nonprofit Organization9
Which status best describes this private nonprofit organization? 10 Please upload documentation to support answer. ☐ Tax exempt under sections 501 (c), (d), or (e) of the Internal Revenue Code. Please provide a ruling letter from the Internal Revenue Service that was in effect on the declaration date and granted tax exemption. ☐ Non-revenue producing under applicable State law. Please provide documentation from the State substantiating it is a non-revenue producing, nonprofit entity organized or doing business under State law. 11 ☐ Exempt from both 501(c)(3) requirements and State tax requirements. Please provide articles of association, bylaws, or other documents indicating it is an organized entity and a certification that it is compliant with Internal Revenue Code section 501(c)(3) and State law requirements. ☐ Other. Please describe12:       Please provide the facility [facilities] owned or operated by the Private Nonprofit. 13
Facility name	Physical address [Street address City, State, ZIP code]			County, Parish, or Municipality14 [system generated]
Does the Applicant own or operate the facility? ☐ Owns and operates the facility. Please upload documentation to support proof of ownership. 15 ☐ Owns, but does not operate the facility (i.e., leases the facility to another entity). Please upload lease or other proof of legal responsibility to repair incident-related damage. 16 ☐ Operates, but does not own the facility (i.e., leases the facility from another entity). Please upload lease or other proof of legal responsibility to repair incident-related damage. ☐ Other. Please describe how the Applicant owns or operates the facility:       What is the primary purpose of the facility? Please select one. Critical Service ☐ Educational: ☐ Primary or secondary education as determined under State law and provided in a day or residential school, including parochial schools. Please upload documentation to support that the school is recognized by the state as providing elementary or secondary education. 17 ☐ Higher-education institution. Please upload documentation to support that the school is recognized or accredited by its State Department of Education. 18 ☐ Emergency Medical Care (diagnosis or treatment of mental or physical injury or disease) provided in: ☐ Clinic ☐ Dialysis facility ☐ Hospice or nursing home ☐ Hospital ☐ In-patient facility ☐ Long-term care facility ☐ Outpatient facility ☐ Rehabilitation center ☐ Other. Please describe:       ☐ Emergency Services: ☐ Ambulance ☐ Fire protection ☐ Public broadcasting that monitors, receives, and/or distributes communication from the Emergency Alert System to the public ☐ Rescue ☐ Other. Please describe:       ☐ Utility: ☐ Communications transmission and switching, and distribution of telecommunications traffic ☐ Electric power generation, transmission, and distribution ☐ Irrigation to provide water for drinking water supply, fire suppression, or electricity generation ☐ Sewer and wastewater collection, transmission, and treatment ☐ Water treatment, transmission, and distribution by a water company supplying municipal water ☐ Other. Please describe:       Non-Critical Essential Social Service ☐ Assisted living facility ☐ Childcare, including center-based childcare. Please upload proof that the State Department of Children and Family Services, Department of Human Services, or similar agency, recognizes it as a licensed childcare facility. 19 ☐ Community center. Please describe services provided:       ☐ Custodial care facility ☐ Day care for individuals with disabilities or access and functional needs ☐ Food assistance programs, including Food Banks and storage of food for Food Banks ☐ Health and safety services, including animal control services ☐ Homeless shelter ☐ House of worship (religious institution) ☐ Library ☐ Low-income housing ☐ Museum ☐ Performing arts center ☐ Rehabilitation facility (not providing medical services as listed in Critical Services above) ☐ Residential or other services for families of domestic abuse or individuals with disabilities ☐ Senior citizen center ☐ Shelter workshop ☐ Zoo ☐ Other. Please describe:       Other. Please describe the primary service the facility provides:       Does the facility provide additional services? 20 ☐ No ☐ Yes. Please describe the other services provided:      . To be eligible for Public Assistance, the primary purpose of the facility must be an eligible service. Please provide proof of the primary service of the facility such as building floorplans; Internal Revenue Service documentation; pre-disaster charter, by-laws, and amendments; evidence of longstanding, routine (day-to-day) use (e.g., a calendar of activities.) 21 Has the Applicant applied for a Small Business Administration (SBA) loan for its infrastructure damage? 22 ☐ No. 23 Applicant must apply for an SBA loan before proceeding.24 ☐ Yes, and the loan was approved. Please upload SBA application and any correspondence. 25 ☐ Yes, and the loan was denied. Please upload SBA application and any correspondence. 26 ☐ Yes, but have not yet received a response. Please upload SBA application and any correspondence. 27 Is access to the facility limited to specific individuals or a specific population? 28 ☐ No ☐ Yes. Please describe how access is limited:       Is there a membership fee or fee to use the facility?29 ☐ No ☐ Yes. Please upload a copy of the fee policy, including rates and any waivers and describe:      30
Section VI – Applicant Acknowledgements and Certifications
I acknowledge and certify that I have reviewed and understand the following information regarding overarching requirements to receive Public Assistance. Please initial next to each statement.       As required by Title VI of the Civil Rights Act of 1964, Sections 308 and 309 of the Stafford Act, and applicable provisions of laws and authorities prohibiting discrimination, all work claimed was [will be] delivered in an impartial and equitable manner.       All information provided regarding the form is true and correct to the best of my knowledge. Upon submittal this form becomes a legal document. The Recipient or FEMA may use external sources to verify the accuracy of the information entered. It is a violation of Federal law to intentionally make false statements or hide information when applying for Public Assistance. The False Claims Act (31 U.S.C. §§3729-3733) prohibits the submission of false or fraudulent claims for payment to the federal government. Suspicion of fraudulent activities should be reported to the FEMA Disaster Fraud Hotline, the Department of Homeland Security's Office of the Inspector General, or the Department of Justice Fraud Hotline. I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain Public Assistance, it is a violation of Federal laws, which carry severe criminal and civil penalties including a fine of up to $250,000, imprisonment, or both. (18 U.S.C. §§ 287, 1001, 1040, and 3571).
Applicant Authorized Representative [system generated]		Title [system generated]	Signature [system generated]	Date submitted [system automated]
Section V – Recipient Recommendation31
Does the Applicant meet the criteria to be an eligible Applicant for Public Assistance funding? ☐ No. Please describe why:       ☐ Yes
What is the Applicant’s non-compliance risk level?32 ☐ High ☐ Medium ☐ Low (Optional) Which factors led to this determination? Please select all that apply. ☐ The Applicant’s prior experience with Public Assistance funding and other awards. ☐ Previous audit findings. ☐ The results of Federal award monitoring. ☐ Other. Please describe:       Does the Recipient recommend that this Applicant be assigned a Program Delivery Manager? 33 ☐ No ☐ Yes
Recipient Authorized Representative [system generated]		Title [system generated]	Signature [system generated]	Date submitted [system automated]

1 Functionality: Generate Declaration # from list of available declarations for Recipient. Generate Declaration Date, Recipient, and Region from Incident Information.

2 Functionality: Generate Legal name, Public Assistance ID, Unique Entity ID #, Physical address, and Mailing address from Organization Profile.

3 (Help Text) Allow information to be updated and reflect changes on Organization Profile.

4 (Help Text) Allow information to be updated and reflect changes on Organization Profile.

5 (Help Text) Climate change represents a profound crisis for the nation, making natural disasters more frequent, more intense, and more destructive. The growing severity of disasters increases the time it takes for communities to recover. These cascading and compounding impacts, propelled by climate change, pose the greatest risk to our communal and nationwide resilience. FEMA provides assistance to help Applicants identify potential mitigation opportunities to increase resiliency for all-hazards. FEMA Specialists can also assist with developing scopes of work and estimating.

6 (Help text) Technology resources to utilize FEMA’s Grants Portal include but are not limited to: High-speed internet connection, computer, and the ability to upload documents to Grants Portal.

7 (Help text) An Applicant Briefing is a meeting conducted by the State, Tribe, or Territory (Recipient) to provide high-level information about the Public Assistance program.

8 (Help Text) Following the President’s declaration, the Recipient conducts briefings for all potential Applicants. The briefings provide high-level information about the Public Assistance Program which can be very helpful. Please contact the State, Tribe, or Territory (Recipient) to inquire about future Applicant Briefings if the Applicant is interested and has not attended a briefing.

9 Functionality: Trigger this section only when “Private Nonprofit Organization” is selected in Organization Profile.

10 Functionality: Support documentation is required before Applicant can submit its Request for Public Assistance.

11 (Help text) Please see the IRS.gov site for Instructions to obtain the Applicant’s exemption letter from IRS.gov.

12 (Help text) Non-government entities that do not meet the criteria outlined in the previous options may not be eligible applicants for Public Assistance. Contact your state, tribe, or territory government Emergency Management Agency for more information.

13 (Help text) In order to determine whether a private nonprofit organization is eligible for Public Assistance, FEMA must first determine whether the PNP owns or operates an eligible facility. See the Private Nonprofit section of the Public Assistance Program and Policy Guide for a list of eligible services. If the Applicant owns or operates multiple facilities, it should complete this section for all facilities that were damaged. Functionality: All facility information should be used to create/update the facility inventory.

14 Functionality: Automated based on physical address provided.

15 (Help text) Proof of ownership includes but is not limited to a deed, title or lease agreement, a bill of sale or land contract, a mortgage payment booklet, a property tax receipt or property tax bill or a real property structure insurance policy. Functionality: Documentation is required prior to submitting a Request for Public Assistance.

16 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

17 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

18 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

19 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

20 Functionality: Triggered only if the primary purpose is a selection under non-critical essential social service or “other”.

21 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

22 Functionality: The question is only triggered if the primary function is a non-critical essential social service or “other”.

23 (Help text) Following a Major Disaster Declaration, the SBA can provide loans for facility restoration. For PNPs with facilities that provide noncritical, essential social services, FEMA is only able provide funding for eligible

Permanent Work costs that an SBA loan will not cover for those facilities. Non-critical PNPs must apply for a disaster loan before proceeding. Please see the Small Business Administration Loan Requirement section of the PAPPG for more information. Functionality: Applicant must apply for an SBA loan and select one of the Yes options before proceeding.

24 (Help Text) The Applicant must apply for an SBA loan prior to submitting the Request for Public Assistance but the Applicant should not wait for the results of the loan before submitting because the Request for Public Assistance is time sensitive.

25 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

26 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

27 Functionality: Documentation is required prior to submitting a Request for Public Assistance.

28 Functionality: The question is only triggered if the primary purpose is a non-critical essential social service or “other”.

29 Functionality: The question is only triggered if the primary purpose is a non-critical essential social service or “other”.

30 Functionality: Documentation is required before the Applicant can submit its Request for Public Assistance.

31 Functionality: The Recipient completes this section prior to submission to FEMA.

32 (Help text) The non-compliance risk is determined by the Recipient holistically considering its experience with the Subrecipient and the requirements as outlined in 2 C.F.R. § 200.331(a).

33 (Help text) In making its recommendation, the Recipient may consider: 1) the Applicant’s risk-level for non-compliance, 2) the Applicant’s level of impacts, 3) whether the Applicant has recently been an eligible Applicant, 4) how frequently the Recipient interacts with the Applicant on the Public Assistance Program, and 5) whether the Applicant has previously navigated the Public Assistance Program successfully without a Program Delivery Manager. Functionality: Response to this question should auto-populate the response to the question “Does the Recipient recommend that this Applicant be assigned a Program Delivery Manager” in Section V – Recipient Recommendation.

FEMA Form FF-104-FY-21-131 1