Fema Request For Public Assistance Form 90 49 – Fill Out and Use This PDF

PNP Checklist

O RPA Form

O Drug Free Workplace Form

O Applicant Certification

O Federal Tax Identification Number Form

O State Tax Exempt Form / IRS Letter

O PNP Questionnaire

OOfficial E-Mail Address

OBack-up Information

OOrganization Charter or By-laws

OPublications/brochures that describe your organization

ODescription of membership policies or fee structures

INSTRUCTION SHEET

REQUEST FOR PUBLIC ASSISTANCE FORM (RPA)

Submitting the Request for Public Assistance (RPA) form is the initial step in filing for the Public Assistance Program. Any governmental entity (village, town, city, county, or state agency), Native American Tribal Organization, or certain private non-profit organizations wishing to apply will be asked to complete a request for public assistance (RPA).

Submittal of the RPA does not make an applicant eligible for public assistance under the Stafford Act. The RPA is used by a potential applicant to indicate interest in the Public Assistance Program.

Applicants should make every effort to complete and return their RPA prior to leaving the applicant briefing. The RPA must be submitted within 30 days of the date of the presidential declaration. If a potential applicant fails to submit the RPA within the specified time frame, they may be denied eligibility for public assistance funds.

On the RPA, the applicant must designate their representative or point of contact. The persons named should have the authority of the chief elected official and should be:

Knowledgeable of the work to be inspected,

Knowledgeable of the location of damages,

Easily accessible by telephone (day & evening), and

Available for future FEMA or State inquiries.

The representatives will also have the overall responsibility to:

Consolidate the disaster documentation activities among departments,

Ensure completion of disaster work, and

Submit applicable reporting forms.

Completing the RPA form: All potential applicants must complete the Request for Public Assistance form. At the top of the form fill in the appropriate declaration number. Enter the date the form is completed. Ensure name, address, and telephone numbers are entered (both home and business number).

CERTIFICATION REGARDING DRUG- FREE WORKPLACE REQUIREMENTS

This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988, 44 CFR Part 17, Subpart F. The regulations, published in the May 25, 1990 Federal Register, require certification by subgrantees, prior to award, that they will maintain a drug-free workplace. The certification set out below is a material representation of fact upon which reliance will be placed when the New York State Emergency Management Office determines to award the subgrant. False certification or violation of the certification shall be grounds for suspension of payments, suspension or termination of grants or government wide suspension or debarment.

(See 44 CFR Part 17, Subpart C, 17.300, and Subpart D, 17.400)

A. The subgrantee certifies that it will or will not continue to provide a drug-free workplace by:

(a) publishing a statement notifying employees that the unlawful manufacture, distribution, dispersing, possession, or use of a controlled substance is prohibited in the subgrantees workplace and specifying the actions that will be taken against employees for violation of such prohibition;

(b)establishing an ongoing drug-free awareness program to inform employees about-

(1)the dangers of drug abuse in the workplace;

(2)the subgrantees policy of maintaining a drug-free workplace;

(3)any available drug counseling, rehabilitation, and employee assistance programs;

(4)the penalties that may be imposed upon the employee for drug abuse violations occurring in the workplace;

(c)making it a requirement that each employee to be engaged in the performance of the sub-grant 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 subgrant, the employee will-

(1)abide by the terms of that statement; and

(2)notify the employer 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 New York State Emergency Management Office in writing within ten calendar days after receiving notice under subparagraph (d) (2) from an employee or otherwise receiving actual notice of such conviction. Such notice shall include the position title of the employee and the federal identification number of the subgrantee.

(f)taking one of the following actions, 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)requiring 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 faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f).

B.The subgrantee may insert in the space provided below the site (s) for the performance of work done in connection with this grant:

Place (s) of Performance: (Please PRINT in the Street address, city, county, state and zip code)

Organization Name: ________________________________________________ Disaster Name: FEMA- _____-DR or EM-NY

(Please Print ) Name and Title of Authorized Representative:______________________________________________________

Signature:_________________________________________________________Date:___________________________________

New York State Office of Emergency Management

PRESIDENTIAL DECLARATION

FEMA-_____-DR / EM-NY

STATE OFFICE of EMERGENCY MANAGEMENT

APPLICANT CERTIFICATION

This is to certify the receipt of the guidelines, and associated documents for the Presidential Declaration as administered by the State Office of Emergency Management (SOEM).

The signature below indicates the intent of the (circle one and PRINT in the name):

County City Town Village State Agency School Fire District Non-profit

of __________________________________________________________________, hereinafter referred

to as the subgrantee, to participate in the Presidential Declaration FEMA-______-DR or EM-NY

The public assistance program is voluntary. It is understood that by choosing to participate in the grant program, the subgrantee is responsible to: 1) comply with all federal and state laws, regulations, policies, and procedures; 2) fulfill the eligibility requirements to participate as a subgrantee of the State; and 3) certify that all figures to be provided in the application are true and correct for costs associated with the declaration provisions.

If debris removal is authorized, the subgrantee agrees to indemnify and hold harmless the State of New York and the United States of America for any claims arising from the removal of debris or wreckage for this disaster. The sub-grantee agrees that debris removal from public and private property will not occur until all state and federal requirements are met.

The undersigned agrees to participate in this program and certifies that to the best of their knowledge and belief, all work and costs claimed are eligible in accordance with the grant conditions and all work claimed has been or will be completed.

SIGNED: ______________________________________	DATE: ____________________________
CHIEF EXECUTIVE OFFICER
NAME: ________________________________________	PHONE NO.: (____)_______-_________
Please type or print name/address

ADDRESS: __________________________________________________________________________

CITY,STATE: _____________________________________________ ZIP CODE: ________________

Designation of the Point of Contact if different from above:

NAME: ________________________________________ PHONE NO.: (____)_______-_________

Please type or print name

TITLE &

ADDRESS: ________________________________________________________________________

FEDERAL TAX IDENTIFICATION NUMBER

(Not for use by State Agencies or Local Political Sub-Divisions)

Disaster No. FEMA-____-DR-NY

In order to process your payment for disaster assistance funds, the State Office of Emergency Management will need to provide the State Comptroller’s Office with your

PAYEE IDENTIFICATION NUMBER.

For an individual, the Payee ID is the social security number. For corporations, including private non-profits, partnerships and other business entities, the Payee ID is the Federal Tax Identification Number (the number used to report Federal withholding taxes to the government). In either case, it is a nine-digit number as follows:

Individual: 123-45-6789

Business: 12-3456789

Federal Tax ID # :____________________________________

Applicant Name:_____________________________________

Applicant Address:____________________________________

City, Zip Code:_______________________________________

Telephone #:_________________________________________

Signature:____________________________ Date:___________

Please provide this number, as it will assist us in providing

your funding in a timely manner.

Please mail or fax it, as soon as possible, to:

Recovery Section

State Office of Emergency Management

1220 Washington Avenue

Building 22, Suite 101

Albany, New York 12226-2251

Fax: 518-322-4984