Applicant Information * Name of Applicant   * State Congressional District   * Type of Applicant State Government Local Government Indian Tribal Government Special Governmental District Private Non-Profit Other If Private Non-Profit,   Legal status, function, and facilities owned:   State Tax Number: (e.g. 11-111111)   Federal Tax Number: (e.g. 11-111111)   If Other, please specify:   * Federal Employer Identification Number (EIN). If Indian Tribe, this is Tribal Identification Number.   * What is your DUNS Number? * Are you the application preparer?  Yes   No * Does your organization have a Smartlink account?  Yes   No * Is the application preparer the Point of Contact?  Yes   No * Is application subject to review by Executive Order 12372 Process?   Yes. This preapplication/application was made available to the Executive Order 12372 Process for review on:        No. Program is not covered by E.O. 12372 Or program has not been selected by state for review * Is the applicant delinquent on any Federal debt?   Yes   No  Explanation:

Contact Information Point of Contact Information Title Mr. Ms. Mrs. Dr. * First Name   Middle Initial   * Last Name   Title   * Agency/Organization   * Address 1   Address 2   * City   * State   * ZIP   * Phone   Fax   * Email     Alternate Point of Contact Information Title Mr. Ms. Mrs. Dr. First Name   Middle Initial   Last Name   Title   Agency/Organization   Address 1   Address 2   City   State   ZIP   Phone   Fax   Email

Subgrant Applications Rank Application Number Application Title Name Non-Federal Share Federal Share Federal Share %

Schedule Subgrant Applicant Total Duration Unit of Time                   Title of your proposed activity   Proposed Period of Performance Overall duration of the grant Unit of Time   Day(s) Week(s) Month(s) Year(s)

Budget File Name Date Attached         Subgrant Applicant Requested Amount         Total $

Properties Property Owner's Name Address City State Zip Code Repetitive Loss Application Number

Assurances and Certifications Forms Status Part I.A.: Assurances Non-Construction Programs. Incomplete/Complete Not Applicable Part I.B.: Assurances Construction Programs. Incomplete/Complete Not Applicable Part II: Certifications Regarding Lobbying; Debarment, Suspension and Other Responsibilities Matters; and Drug-Free Workplace Requirements. Incomplete/Complete Part III: Disclosure of Lobbying Activities (Complete only if applying for a grant of more than $100,000 and have lobbying activities using Non-Federal funds. See Form 20-16C for lobbying activities definition.) Incomplete/Complete Not Applicable

Assurances-Non-Construction Programs Attachments

I, ______________________________, hereby sign this form as of _______________.

Assurances-Construction Programs Attachments

I, ______________________________, hereby sign this form as of _______________.

Certifications Regarding Lobbying; Debarment, Suspension and Other Responsibilities Matters; and Drug-Free Workplace Requirements. Attachments   Section 17.630 of the regulations provide that a grantee that is a State may elect to make one certification in each Federal fiscal year. A copy of which should be included with each application for FEMA funding. States and State agencies may elect to use a Statewide certification.

I, ______________________________, hereby sign this form as of _______________.

Disclosure of Lobbying Activities Attachments

I, ______________________________, hereby sign this form as of _______________.