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,   Describe the 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 * 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: (MM-DD-YYYY e.g. 02-05-2003) 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  If yes, type explanation:   * Community:   Is this a small, impoverished community? (Note: For PDM-C grants, a response to this question is required.) Yes   No

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

* Community Information Please provide the name of each community that will benefit from this mitigation activity. County Code Community Name CID Number CRS Community CRS Rating State Legislative District US Congressional District State                                                 Community Profile   If you would like to make any comments, please enter them below   Attachments

Mitigation Plan Information * Is the entity that will benefit from the proposed activity covered by a current FEMA-approved multihazard mitigation plan in compliance with 44 CFR Part 201? Yes   No    Not Known If yes, please answer the following: * What is the name of the plan?   * What is the type of plan? Local MultiJurisdictional Multihazard Mitigation Plan Local Multihazard Mitigation Plan Tribal (Local) MultiJurisdictional Multihazard Mitigation Plan Tribal (Local) Multihazard Mitigation Plan Tribal Mitigation Plan * When was the current multihazard mitigation plan approved by FEMA?   * Describe how the proposed activity relates to or is consistent with the FEMA-approved mitigation plan.   If no or not known, please answer the following: * Does the entity have any other mitigation plans adopted? Yes   No   Not Known   If yes, please provide the following information. Plan Name Plan Type Date Adopted Attachment                         * Does the State/Tribe in which the entity is located have a current FEMA-approved mitigation plan in compliance with 44 CFR Part 201?  Yes  No If yes, please answer the following: * What is the name of the plan?    * What is the type of plan? Enhanced State Multi-hazard Mitigation Plan Enhanced Tribal Multi-hazard Mitigation Plan Standard State Multi-hazard Mitigation Plan Standard Tribal Multi-hazard Mitigation Plan State Mitigation Plan - Pre DMA2000 Tribal Mitigation Plan * When was the current mitigation plan approved by FEMA?    * Describe how the proposed activity relates to or is consistent with the State/Tribe's FEMA-approved mitigation plan.   If you would like to make any comments, please enter them below.   Attachments:

Mitigation Activity Information * What type of activity are you proposing? (Please choose activities from Appendix A below).   If you selected Other or Miscellaneous, above, please specify:   * Title of your proposed activity(should include the type of activity and location):   * Are you doing construction in this project? Yes   No If you would like to make any comments, please enter them below.     Attachments:

Hazard Information Problem Description: please describe the problem to be mitigated. Include the geographic area in your description.   Enter the Latitude and Longitude coordinates for the project area. Latitude:   Longitude:   Attachments:

Hazards Select hazards to be mitigated: Biological Chemical Civil Unrest Coastal Storm Crop Losses Dam/Levee Break Drought Earthquake Fire Fishing Losses Flood Freezing Human Cause Hurricane Land Subsidence Mud/Landslide Nuclear Other Severe Ice Storm Severe Storm(s) Snow Special Events Terrorist Tornado Toxic Substances Tropical Cyclones Tsunami Typhoon Volcano Windstorms If other hazards, please specify   If you would like to make any comments, please enter them below.   Attachments:

FIRM Information * Is the project located within hazard area? Floodplain Other identified high hazard area No If other identified high hazard area, please specify:   *Is there a Flood Insurance Rate Map (FIRM) or Flood Hazard Boundary Map (FHBM) available for your project area? If you have selected Yes, the following three fields are required: Yes     No Enter FIRM Panel Number:   check if Not Applicable Mark your project site on the FIRM/FHBM (even if it is out of the floodplain) Electronic map attached Hard copy provided Not Applicable Select Flood Zone Designation C, X B, X N AR A99 A1-30, AE A A0 V0 AH V1-30, VE V E M D P

Scope of Work * What are the goals and objectives of this activity?   * Briefly describe the need for this activity.   * Describe the problems this activity will address.   * Describe the methodology for implementing this activity.   If you would like to make any comments, please enter them below.     Attachments:

Enter Work Schedule Description Of Task Starting Point Unit Of Time Duration Unit Of Time Work Complete By                                     * Estimate the total duration of the proposed activity:   Day(s) Week(s) Month(s) Year(s)

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

* Activity:

Damaged Property Address: * Address line 1 Street Number: Direction: East    North    North East    North West South    South East    South West    West Street Name: Street Type: Avenue    Boulevard    Branch    Causeway    Center Circle    Common    Corner    Course    Court Crescent    Drive    Expressway    Freeway    Grove Highway    Island    Isle    Junction    Lake Land    Mall    Motorway    Other    Parkway Pike    Place    Plains    Plaza    Point Ridge    Road    Route    Square    Street Terrace    Trace    Trail    Turnpike    Valley View    Village    Ville    Walk    Way If Other, Specify Street Type: Direction: East    North    North East    North West South    South East    South West    West Address line 2 Unit Type: Apartment Basement Building Department Floor Front Hanger Key Lobby Lot Lower Office Other Penthouse Pier Rear Room Side Slip Space Stop Suite Trailer Unit Upper If Other, Specify Unit Type: Number: * City   * County * State   * ZIP   Owner Information: If the owner is an organization, then split this information in the First and Last Name. * First Name Middle Name * Last Name Phone Home Office     Cell Other     Owner's Mailing Address (check if this address is the same as Property Address above): Address line 1 Street Number: Direction: East    North    North East    North West South    South East    South West    West Street Name: Street Type: Avenue    Boulevard    Branch    Causeway    Center Circle    Common    Corner    Course    Court Crescent    Drive    Expressway    Freeway    Grove Highway    Island    Isle    Junction    Lake Land    Mall    Motorway    Other    Parkway Pike    Place    Plains    Plaza    Point Ridge    Road    Route    Square    Street Terrace    Trace    Trail    Turnpike    Valley View    Village    Ville    Walk    Way If Other, Specify Street Type: Direction: East    North    North East    North West South    South East    South West    West Address line 2 Unit Type: Apartment Basement Building Department Floor Front Hanger Key Lobby Lot Lower Office Other Penthouse Pier Rear Room Side Slip Space Stop Suite Trailer Unit Upper If Other, Specify Unit Type: Number: Other (PO Box, Route, etc)   City   State   ZIP   *Does this property have other co-owners or holders of recorded interest? Yes    No

If Yes, Enter Co-owner or Owner of Property Interest Information: If the co-owner is an organization, then split this information in the First and Last Name. *First Name Middle Name *Last Name Phone Home Office     Cell Other     Co-owner's Mailing Address: Owner's Mailing Address    Property Address    None Address line 1 Street Number: Direction: East    North    North East    North West South    South East    South West    West Street Name: Street Type: Avenue    Boulevard    Branch    Causeway    Center Circle    Common    Corner    Course    Court Crescent    Drive    Expressway    Freeway    Grove Highway    Island    Isle    Junction    Lake Land    Mall    Motorway    Other    Parkway Pike    Place    Plains    Plaza    Point Ridge    Road    Route    Square    Street Terrace    Trace    Trail    Turnpike    Valley View    Village    Ville    Walk    Way If Other, Specify Street Type: Direction: East    North    North East    North West South    South East    South West    West Address line 2 Unit Type: Apartment Basement Building Department Floor Front Hanger Key Lobby Lot Lower Office Other Penthouse Pier Rear Room Side Slip Space Stop Suite Trailer Unit Upper If Other, Specify Unit Type: Number: Other (PO Box, Route, etc) City   State   ZIP

Comments Attachments:

Property Information: Age of structure (year built) Review Yes No Not Applicable Unknown Reviewed Date   * Structure Type 2-4 Family Manufactured Home Multi-Family Dwelling - 5 or More Units Non-residential - Private Non-residential - Public Other (Specify in Comments) Single Family Vacant Land If Other Structure Type, please specify   Foundation type Basement Crawl Space Elevated on Piers, Piles, Posts or Columns Other (Specify in Comments) Slab on Grade Vacant Land If Other Foundation Type, please specify   Basement Yes   No Type of Residence Not Applicable Other Owner Occupied- Secondary Residence Owner Occupied-Principal Residence Rental If Other Type of Residence, please specify   Parcel Number Property Tax Identification Number Does this property have a (Note: For SRL grants, a response to this question is required.) Yes   No If Yes, then provide policy Number Insurance Company * Select hazards to be mitigated: Biological Chemical Civil Unrest Coastal Storm Crop Losses Dam/Levee Break Drought Earthquake Fire Fishing Losses Flood Freezing Human Cause Hurricane Land Subsidence Mud/Landslide Nuclear Other Severe Ice Storm Severe Storm(s) Snow Special Events Terrorist Tornado Toxic Substances Tropical Cyclones Tsunami Typhoon Volcano Windstorms If other hazards, please specify   * Damage Category 0-49% Damaged 100% Damaged 50-99% Damaged Not Applicable Performed Yes No Not Applicable Unknown Benefit Cost Ratio Repetitive Loss Structure Yes No Unknown Number of Losses 2-3 Losses Cumulatively > building Fair Market Value 2-3 Losses Cumulatively <= building Fair Market Value 4 or More insured losses since 1978 Not Applicable Legal Description

Property Information II: * Primary Property Action Acquisition of Vacant Land Acquisition/Demolition Acquisition/Relocation Elevation Floodproofed Other Safe Room/Wind Shelter Seismic Retrofit Wind Retrofit If Other Primary Action, please specify   Secondary Property Actions Acquisition of Vacant Land Acquisition/Demolition Acquisition/Relocation Elevation Floodproofed Other Safe Room/Wind Shelter Seismic Retrofit Wind Retrofit If Other Secondary Property Action, please specify   Flood Hazard Base Flood Elevation       feet       feet Number of feet the lowest floor elevation of the structure is being raised above Base Flood Elevation (only applicable when Property Action is Elevation)       feet Flood Source Closed Basin Coastal Basin Other Riverine Flooding Stormwater Runoff           If Other Flood Source, please specify Is the property located within  Not Applicable Floodway Floodplain Other identified high hazard area           If Other Location, please specify Is there a Flood Insurance Rate Map (FIRM) or other Flood Maps available for your project area?  Yes  No  Unknown Is the property site marked on the map? Yes, map attached No, hard copy of map will be provided Not Applicable Select Flood Zone Designation C, X B, X N AR A99 A1-30, AE A A0 V0 AH V1-30, VE V E M D P If Other Flood Zone Designation, please specify

FIRM Information (Flood Maps) Community Name CID Number FIRM Panel Number Effective Date

Comments Attachments:

Decision Making Process Describe the process you used to decide that this project is the best solution to the problem. Below are some questions to consider as you write your narrative:   Are you focusing on the area in your community that has the greatest potential for losses?   Have you considered the risks to critical facilities and structures and benefits to be obtained by mitigating this vulnerability?   Have you considered those areas or projects that present the greatest opportunities given the current situation and interest in your community?   Are you addressing a symptom or the source of the problem? Addressing the source of the problem is a long-term solution which provides the most mitigation benefits.   If impacts to the environmental/historic preservation, natural, cultural or historic resources have been identified, explain how your alternatives and proposed project address, minimize, or avoid these impacts?   Explain why this project is the best alternative.   If you would like to make any comments, please enter them below.   Attachments.

* Cost Estimate Item Name Cost Classification Grant Budget Class Subgrant Budget Class Unit Quantity Unit of Measure Unit Cost ($) Cost Estimate ($)                                                 * Total Cost Estimate $

Match Sources Total Cost Estimate   Federal Share Percentage   Non-Federal Share Percentage     Dollars Percentage * Proposed Federal Share $ %  * Proposed Non-Federal Share $ %

* Matching Funds Source Agency Name of Source Agency Funding Type Amount ($)                         Grand Total $ If you would like to make any comments, please enter them below.   Attachments:

Cost Effectiveness Information Attach the Benefit Cost Analysis (BCA), if completed for this project   * What is the source and type of the problem?   * How frequent is the event?   * How severe is the damage?   * What kind of properties are at risk?   * Are there better, alternative ways to solve the problem?   * Are the mitigation project costs well documented and reasonable?  Yes   No If you would like to make any comments, please enter them below.   Attachments:

Damage History * Date * Event * Description of Damage * Amount of Damage                         Total Amount of Damage $

A. National Historic Preservation Act - Historic Buildings and Structures   * 1. Does your project affect or is it in close proximity to any buildings or structures 50 years or more in age? Yes No Not known   If Yes, you must confirm that you have provided the following:   The property address and original date of construction for each property affected (unless this information is already noted in the Properties section),         A minimum of two color photographs showing at least three sides of each structure (Please label the photos accordingly),         A diagram or USGS 1:24,000 scale quadrangle map displaying the relationship of the property(s) to the project area.   To help FEMA evaluate the impact of the project, please indicate below any other information you are providing:   Information gathered about potential historic properties in the project area, including any evidence indicating the age of the building or structure and presence of buildings or structures that are listed or eligible for listing on the National Register of Historic Places or within or near a National Register listed or eligible historic district. Sources for this information may include the State Historic Preservation Officer, and/or the Tribal Historic Preservation Officer (SHPO/THPO), your local planning office, historic preservation organization, or historical society.         Consideration of how the project design will minimize adverse effects on known or potential historic buildings or structures, and any alternatives considered or implemented to avoid or minimize effects on historic buildings or structures. Please address and note associated costs in your project budget.         For acquisition/demolition projects affecting historic buildings or structures, any data regarding the consideration and feasibility of elevation, relocation, or flood proofing as alternatives to demolition.         Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

B. National Historic Preservation Act - Archeological Resources   * 1. Does your project involve disturbance of ground? Yes No Not Known   If Yes, you must confirm that you have provided the following:   A description of the ground disturbance by giving the dimensions (area, volume, depth, etc.) and location    The past use of the area to be disturbed, noting the extent of previously disturbed ground.    A USGS 1:24,000 scale or other site map showing the location and extent of ground disturbance.   To help FEMA evaluate the impact of the project, please indicate below any other information you are providing:   Any information about potential historic properties, including archeological sites, in the project area. Sources of this information may include SHPO/THPO, and/or the Tribe's cultural resources contact if no THPO is designated. Include, if possible, a map showing the relation of any identified historic properties to the project area.    Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

C. Endangered Species Act and Fish and Wildlife Coordination Act   * 1. Are Federally listed threatened or endangered species or their critical habitat present in the area affected by the project? Yes No Not Known    If Yes, you must confirm that you have provided the following:          Information you obtained to identify species in or near the project area. Provide the source and date of the information cited.          To help FEMA evaluate the impact of the project, please indicate below any other information you are providing:    Any request for information and associated response from the USFWS, the National Marine Fisheries Service (NMFS) (for affected ocean-going fish), or your State Wildlife Agency, regarding potential listed species present and potential of the project to impact those species.     Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): * 2. Does your project remove or affect vegetation? Yes No Not Known     If Yes, you must confirm that you have provided the following:     Description of the amount (area) and type of vegetation to be removed or affected.     A site map showing the project area and the extent of vegetation affected.     Photographs or digital images that show both the vegetation affected and the vegetation in context of it surroundings.     To help FEMA evaluate the impact of the project, please indicate below any other information you are providing:         Attached materials or additional comments.       Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): * 3. Is your project in, near (within 200 feet), or likely to affect any type of waterway or body of water? Yes No Not Known    If Yes, and project is not within an existing building, you must confirm that you have provided the following:         A USGS 1:24,000 scale quadrangle map showing the project activities in relation to all nearby water bodies (within 200 feet).         Any information about the type of water body nearby including: its dimensions, the proximity of the project activity to the water body, and the expected and possible changes to the water body, if any. Identify all water bodies regardless whether you think there may be an effect         A photograph or digital image of the site showing both the body of water and the project area.    To help FEMA evaluate the impact of the project, please indicate below any other information you are providing:         Evidence of any discussions with the US Fish and Wildlife Service (USFWS), and/or your State Wildlife Agency concerning any potential impacts if there is the potential for the project to affect any water body.         Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

D. Clean Water Act, Rivers and Harbors Act, and Executive Order 11990 (Protection of Wetlands)   * 1. Will the project involve dredging or disposal of dredged material, excavation, adding fill material or result in any modification to water bodies or wetlands designated as "waters of the U.S" as identified by the US Army Corps of Engineers or on the National Wetland Inventory? Yes No Not Known      If Yes, you must confirm that you have provided the following:             Documentation of the project location on a USGS 1:24,000 scale topographic map or image and a copy of a National Wetlands Inventory map or other available wetlands mapping information.              To help FEMA evaluate the impact of the project, please indicate below any other information you are providing:     Request for information and response letter from the US Army Corps of Engineers and/or State resource agencies regarding the potential for wetlands, and applicability of permitting requirements.             Evidence of alternatives considered to eliminate or minimize impacts to wetlands.             Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

E. Executive Order 11988 (Floodplain Management)   * 1. Does a Flood Insurance Rate Map (FIRM), Flood Hazard Boundary Map (FHBM), hydrologic study, or some other source indicate that the project is located in or will affect a 100 year floodplain, a 500 year floodplain if a critical facility, an identified regulatory floodway, or an area prone to flooding? Yes No Not Known           If Yes, please indicate in the text box below any documentation to identify the means or the alternatives considered to eliminate or minimize impacts to floodplains (See the 8 step process found in 44 CFR Part 9.6.) to help FEMA evaluate the impact of the project (If you selected Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): * 2. Does the project alter a watercourse, water flow patterns, or a drainage way, regardless of its floodplain designation? Yes No Not Known           If Yes, please indicate below any other information you are providing to help FEMA evaluate the impact of the project:     Hydrologic/hydraulic information from a qualified engineer to demonstrate how drainage and flood flow patterns will be changed and to identify down and upstream effects.     Evidence of any consultation with US Army Corps of Engineers (may be included under Part D of the Environmental Information).     Request for information and response letter from the State water resource agency, if applicable, with jurisdiction over modification of waterways.     Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

F. Coastal Zone Management Act   * 1. Is the project located in the State's designated coastal zone? Yes No Not Known             If Yes, please indicate below any other information you are providing to help FEMA evaluate the impact of the project:     Information resulting from contact with the appropriate State agency that implements the coastal zone management program regarding the likelihood of the project’s consistency with the State’s coastal zone plan and any potential requirements affecting the cost or design of the proposed activity.            Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

G. Farmland Protection Policy Act   * 1. Will the project convert more than 5 acres of “prime or unique” farmland outside city limits to a non- agricultural use? Yes No Not Known Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

H. RCRA and CERCLA (Hazardous and Toxic Materials)   * 1. Is there a reason to suspect there are contaminants from a current or past use on the property associated with the proposed project? Yes No Not Known             If Yes, please indicate below any other information you are providing to help FEMA evaluate the impact of the project:     Comments and any relevant documentation.              Results of any consultations with State or local agency to obtain permit with requirements for handling, disposing of or addressing the effects of hazardous or toxic materials related to project implementation.             Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): * 2. Are there any studies, investigations, or enforcement actions related to the property associated with the proposed project? Yes No Not Known             If Yes, please indicate below any other information you are providing to help FEMA evaluate the impact of the project:     Comments and any relevant documentation.              Results of any consultations with State or local agency to obtain permit with requirements for handling, disposing of or addressing the effects of hazardous or toxic materials related to project implementation.             Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): * 3. Does any project construction or operation activities involve the use of hazardous or toxic materials? Yes No Not Known             If Yes, please indicate below any other information you are providing to help FEMA evaluate the impact of the project:     Comments and any relevant documentation.              Results of any consultations with State or local agency to obtain permit with requirements for handling, disposing of or addressing the effects of hazardous or toxic materials related to project implementation.             Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): * 4. Do you know if any of the current or past land-uses of the property affected by the proposed project or of the adjacent properties are associated with hazardous or toxic materials? Yes No Not Known             If Yes, please indicate below any other information you are providing to help FEMA evaluate the impact of the project:     Comments and any relevant documentation.              Results of any consultations with State or local agency to obtain permit with requirements for handling, disposing of or addressing the effects of hazardous or toxic materials related to project implementation.             Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

I. Executive Order 12898, Environmental Justice for Low Income and Minority Populations   * 1. Are there low income or minority populations in the project’s area of effect or adjacent to the project area? Yes No Not Known             If Yes, you must confirm that you have provided the following:             Description of any disproportionate and adverse effects to these populations.                     To help FEMA evaluate the impact of the project, please indicate below any other information you are providing:      Description of the population affected and the portion of the population that would be disproportionately and adversely affected. Please include specific efforts to address the adverse impacts in your proposal narrative and budget.      Attached materials or additional comments. Please enter your comments below (If you selected Yes or Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

J. Other Environmental/Historic Preservation Laws or Issues   * 1. Are there other environmental/historic preservation requirements associated with this project that you are aware of? Yes No             If Yes, please indicate in the text box below a description of the requirements, issues or public involvement effort. * 2. Are there controversial issues associated with this project? Yes No Not Known             If Yes, please indicate in the text box below a description of the requirements, issues or public involvement effort (If you selected Not Known above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): * 3. Have you conducted any public meeting or solicited public input or comments on your specific proposed mitigation project? Yes No             If Yes, please indicate in the text box below a description of the requirements, issues or public involvement effort. Attachments:

K. Summary and Cost of Potential Impacts      * 1. Having answered the questions in parts A. through J., have you identified any aspects of your proposed project that have the potential to impact environmental resources or historic properties? Yes No   If Yes, you must confirm that you have:   Evaluated these potential effects and provided the materials required in Parts A through J that identify the nature and extent of potential impacts to environmental resources and/or historic properties.         Consulted with appropriate parties to identify any measures needed to avoid or minimize these impacts.         Considered alternatives that could minimize both the impacts and the cost of the project.         Made certain that the costs of any measures to treat adverse effects are realistically reflected in the project budget estimate. Please enter your comments below (If you selected Yes above, please indicate why in the text box below and any information about this project that could assist FEMA in its review.): Attachments:

Maintenance Schedule and Costs Provide a maintenance schedule including cost information   Identify entity that will perform any long-term maintenance   If you would like to make any comments, please enter them below.   Attach letter from entity accepting performance responsibility

Evaluation Information By checking the Not Applicable box and not providing the information in this section, I understand that this application may not be selected for the Pre-Disaster Mitigation - Competitive Grant Program. Incomplete/Complete Not applicable

Evaluation Information (Part 1 of 4) * Is the recipient participating in the Community Rating System (CRS)?  Yes  No           If yes, what is their CRS rating? 1   2   3   4 5   6   7   8 9   10 * Is the recipient a Cooperating Technical Partner (CTP)?  Yes  No * Is the recipient a Firewise Community?  Yes  No           If yes, please provide their Firewise Community number.    * Has the recipient adopted building codes consistent with the International Codes?  Yes  No * Has the recipient adopted the National Fire Protection Association (NFPA) 5000 Code?  Yes  No * Have the recipient's building codes been assessed on the Building Code Effectiveness Grading Schedule (BCEGS)?  Yes  No          If yes, what is their BCEGS rating? 1   2   3   4 5   6   7   8 9   10 * Is the recipient a Disaster Resistant University?  Yes  No * Is the recipient a Historically Black College or University / Tribal College or University?  Yes  No

Evaluation Information (Part 2 of 4) * Describe the desired outcome and methodology of the mitigation activity in terms of mitigation objectives to be achieved.   * Describe performance expectations and timeline for interim milestones and overall completion of mitigation activity.   * Describe how you will manage the costs and schedule, and how you will ensure successful performance.   * Describe the staff and resources needed to implement this mitigation activity and the applicant's ability to provide these resources.   * If applying for multiple mitigation activities, how do these activities relate?

Evaluation Information (Part 3 of 4) * How will this mitigation activity leverage involvement of partners to enhance its outcome?   * How will this mitigation activity offer long-term financial and social benefits?   * How does this mitigation activity comply with Federal laws and Executive Orders, and how is it complementary to other Federal programs?   * What outreach activities are planned relative to this mitigation activity (e.g., signs, press releases, success stories, developing package to share with other communities, losses avoided analysis) and/or how will this mitigation activity serve as a model for other communities (i.e., Do you intend to mentor other communities, Tribes or States? Do you intend to prepare a description of the process followed in this activity so that others may learn from the example?)?

Evaluation Information (Part 4 of 4) * Please provide the percent of the population benefiting from this mitigation activity.       % * Please explain your response to the above question.   * Net Present Value of Project Benefits (A) $   * Total Project Cost Estimate (B) $   * What is the Benefit Cost Ratio for the entire project (A/B)?   * Analysis Type  FEMA BCA software methodology Other FEMA-approved BCA methodology Repetitive Loss alternate methodology * What was the primary hazard data used for the BCA? Coastal Storm Earthquake Fire Flood Freezing Hurricane MudLandslide Severe Ice Storm Severe Storm(s) Snow Tornado Tsunami Typhoon Volcano Windstorms What secondary hazards were considered during the BCA? Biological Chemical Civil Unrest Coastal Storm Crop Losses Dam/Levee Break Drought Earthquake Fire Fishing Losses Flood Freezing Human Cause Hurricane Land Subsidence Mud/Landslide Nuclear Other Severe Ice Storm Severe Storm(s) Snow Special Events Terrorist Tornado Toxic Substances Tropical Cyclones Tsunami Typhoon Volcano Windstorms Other Secondary Hazard   * Does this mitigation activity protect a critical facility? Yes  No If yes, please select the type of critical facilities to be protected Hazardous Materials Facilities Emergency Operation Centers Power Facilities Water Facilities Sewer and wastewater treatment Facilities Communications Facilities Emergency Medical Care Facilities Fire Protection Emergency Facilities If you would like to make any comments, please enter them below.   Attachments:

Assurances and Certifications Forms Status Part I: FEMA Form 20-16A, Assurances Non-Construction Programs / FEMA Form 20-16B, Assurances Construction Programs. Incomplete/Complete Not Applicable Part II: FEMA Form 20-16C, Certifications Regarding Lobbying; Debarment, Suspension and Other Responsibilities Matters; and Drug-Free Workplace Requirements. Incomplete/Complete Part III: SF-LLL, 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

FEMA Form 20-16A, Assurances-Non-Construction Programs Note: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.   As the duly authorized representative of the applicant, I certify that the applicant: 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non-Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Will comply with the Intergovernmental Personnel Act of 1970 (42 USC Section 4728-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 CFR 900, Subpart F). 6. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 USC Section 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 USC Section 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 USC Section 6101-6107), which prohibits discrimination on the basis of age; (e) The Drug Abuse Office and Treatment Act of 1972 (PL 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912 (42 USC 290-dd-3 and 290-ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 USC Section 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) Any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j)The requirements of any other nondiscrimination statute(s) which may apply to the application. 7. Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (PL 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply with the provisions of the Hatch Act (5 USC Section 1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of Davis-Bacon Act (40 USC Section 276a to 276a-7), Copeland Act (40 USC Section 276c and 18 USC 874), and the Contract Work Hours and Safe Standards Act (40 USC Section 327-333), regarding labor standards for federally assisted construction subagreements. 10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (PL 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 USC Section I' 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 USC Section I 7401 et seq.); (g) protection of underground source of drinking water under the Safe Drinking Water Act of 1974, as amended, (PL 93-523); and (h) protection of endangered species under the Endangered Special Act of 1973, as amended, (PL 93-205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 USC Section 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 USC Section 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 USC Section 469a-1 et seq.) 14. Will comply with PL 93-348 regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (PL 89-544, as amended, 7 USC 2131 et seq.) pertaining to the care, handling, treatment of warm blooded animals held research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 USC Section 4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program. 19. It will comply with the minimum wage and maximum hours provisions of the Federal Fair Labor Standards Act (29 USC Section 201), as they apply to employees of institutions of higher education, hospitals, and other non-profit organizations.

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

FEMA Form 20-16B: Assurances-Construction Programs Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0042), Washington, DC 20503. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY. NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the awarding agency. Further, certain Federal assistance awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified. As the duly authorized representative of the applicant, I certify that the applicant: 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the nonfederal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Comptroller General of the United States and, if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the assistance; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will not dispose of, modify the use of, or change the terms of the real property title, or other interest in the site and facilities without permission and instructions from the awarding agency. Will record the Federal interest in the title of real property in accordance with awarding agency directives and will include a covenant in the title of real property acquired in whole or in part with Federal assistance funds to assure nondiscrimination during the useful life of the project. 4. Will comply with the requirements of the assistance awarding agency with regard to the drafting, review and approval of construction plans and specifications. 5. Will provide and maintain competent and adequate engineering supervision at the construction site to ensure that the complete work conforms with the approved plans and specifications and will furnish progress reports and such other information as may be required by the assistance awarding agency or state. 6. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 7. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain. 8. Will comply with the Intergovernmental Personnel Act of 1970 (42 USC Sections 4728-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statues or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 CFR 900, Subpart F). 9. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 USC Section 4801 et seq.) which prohibits the use of lead based paint in construction or rehabilitation of residence structures. 10. Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 USC Sections 1681- 1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 USC Section 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 USC Sections 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (PL 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912 (42 USC Sections 290-dd-3 and 290-ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 USC Section 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (I) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and, (j) the requirements of any other nondiscrimination statute(s) which may apply to the application. 11. Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (PL 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal and Federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 12. Will comply with the provisions of the Hatch Act (5 USC Sections 1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 13. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 USC Sections 276a to 276a-7), the Copeland Act (40 USC Section 276c and 18 USC Section 874), and the Contract Work Hours and Safety Standards Act (40 USC Sections 327-333) regarding labor standards for federally assisted construction subagreements. 14. Will comply with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (PL 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more. 15. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (PL 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 USC Section 1451 et seq.); (f) conformity of Federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 USC Section 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (PL 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended (PL 93-205). 16. Will comply with the Wild and Scenic Rivers Act of 1968 (16 USC Section 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. 17. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 USC Section 470), EO 11593 (identification and preservation of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 USC Section 469a-1 et seq.). 18. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984. 19. Will comply with all applicable requirements of all other Federal laws, Executive Orders, regulations, and policies governing this program. 20. It will comply with the minimum wage and maximum hour provisions of the Federal Fair Labor Standards Act (29 USC Section 201), as they apply to employees of institutions of higher education, hospitals, and other nonprofit organizations. 21. It will obtain approval by the appropriate Federal agency of the final working drawings and specifications before the project is advertised or placed on the market for bidding; that it will construct the project, or cause it to be constructed, to final completion in accordance with the application and approved plans and specifications; that it will submit to the appropriate Federal agency for prior approval changes that alter the cost of the project, use of space, or functional layout, that it will not enter into a construction contract(s) for the project or undertake other activities until the conditions of the construction grant program(s) have been met. 22. It will operate and maintain the facility in accordance with the minimum standards as may be required or prescribed by the applicable Federal, State, and local agencies for the maintenance and operation of such facilities. 23. It will require the facility to be designed to comply with the "American Standard Specification for Making Buildings and Facilities Accessible to, and Usable by, the Physically Handicapped," Number A117.- 1961, as modified (41 CFR 101-17.703). The applicant will be responsible for conducting inspections to ensure compliance with these specifications by the contractor. 24. If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the applicant, this assurance shall obligate the applicant, or in the case of any transfer of such property, any transfer, for the period during which the real property, or structure is used for a purpose for which the Federal financial assistance is extended or for another purpose involving the provision of similar services or benefits. 25. In making subgrants with nonprofit institutions under this Comprehensive Cooperative Agreement, it agrees that such grants will be subject to OMB Circular A-122, "Cost Principles for Nonprofit Organizations" included in Vol. 49, Federal Register, pages 18260 through 18277 (April 27, 1984).

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

FEMA Form 20-16C Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the instructions for certification included in the regulations before completing this form. Signature on this form provides for compliance with certification requirements under 44 CFR Part 18, "New Restrictions on Lobbying; and 28 CFR Part 17, "Government-wide Debarment and suspension (Non-procurement) and Government-wide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a material representation of fact upon which reliance will be placed when the Federal Emergency Management Agency (FEMA) determines to award the covered transaction, grant, or cooperative agreement. 1. LOBBYING A. As required by the section 1352, Title 31 of the US Code, and implemented at 44 CFR Part 18 for persons entering into a grant or cooperative agreement over $100,000, as defined at 44 CFR Part 18, the applicant certifies that: (a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with the making of any Federal grant, the entering into of any cooperative agreement and extension, continuation, renewal, amendment, or modification of any Federal grant or cooperative agreement; (b) If any other funds than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure of Lobbying Activities", in accordance with its instructions;  Standard Form LLL Disclosure of Lobbying Activities Attached (c) The undersigned shall require that the language of this certification be included in the award documents for all the sub awards at all tiers (including subgrants, contracts under grants and cooperative agreements, and subcontract(s)) and that all subrecipients shall certify and disclose accordingly. 2. DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS (DIRECT RECIPIENT) As required by Executive Order 12549, Debarment and Suspension, and implemented at 44 CFR Part 67, for prospective participants in primary covered transactions, as defined at 44 CFR Part 17, Section 17.510-A. The applicant certifies that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, sentenced to a denial of Federal benefits by a State or Federal court, or voluntarily excluded from covered transactions by any Federal department or agency; (b) Have not within a three-year period preceding this application been convicted of or had a civilian judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or perform a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or locally) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and (d) Have not within a three-year period preceding this application had one or more public transactions (Federal, State, or local) terminated for cause or default; and B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application. Explanation: 3. DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS) As required by the Drug-Free Workplace Act of 1988, and implemented at 44 CFR Part 17, Subpart F, for grantees, as defined at 44 CFR part 17, Sections 17.615 and 17.623: (A) The applicant certifies that it will continue to provide a drug-free workplace by: (a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing an on-going drug free awareness program to inform employees about: (1) The dangers of drug abuse in the workplace; (2) The grantee's policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation and employee assistance programs; and (4) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (c) Making it a requirement that each employee to be engaged in the performance of the grant to be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will: (1) Abide by the terms of the statement; and (2)Notify the employee in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction. (e) Notifying the agency, in writing within 10 calendar days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to the applicable FEMA awarding office, i.e. regional office or FEMA office. (f) Taking one of the following actions against such an employee, within 30 calendar days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted: (1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Require such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement or other appropriate agency. (g) Making a good effort to continue to maintain a drug free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f). (B) The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: * Place of Performance Street City State Zip             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 _______________.

Standard Form LLL: Disclosure of Lobbying Activities * 1. Type of Federal Action           a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance * 2. Status of Federal Action           a. bid/offer/application b. initial award c. post award * 3. Report Type           a. initial filling b. material change For Material Change Only :   year : quarter : date of last report : 4. * Name and Address of Reporting Entity: Reporting Entity Type:  Prime          Subawardee Tier, if known:              Congressional District, if known: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name and Address of Prime: Congressional District, If known: * 6. Federal Department/Agency * 7. Federal Program Name/Description CFDA Number, if applicable: 8. Federal Action Number, if Known: 9. Award Amount, if Known:   $ 10a. Name and address of Lobbying Registrant: (if individual, last name, first name, MI) 10b. Individuals Performing Services: (including address if different from No.10a) (last name, first name, MI) 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

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