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									                              U.S. DEPARTMENT OF HOMELAND SECURITY
                             FEDERAL EMERGENCY MANAGEMENT AGENCY                                                 O.M.B. NO. 1660-0058
                                                                                                                 Expires July 31, 2008
                                                PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to be 10 minutes per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. Your
response is required to obtain or retain Federal Assistance through FEMA’s Fire Management Assistance Grant Program. You are not
required to respond to this collection of information unless a valid OMB control number is displayed in the upper right hand corner of
this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden, to: Information
Collections Management, U.S. Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW,
Washington, D.C. 20472, Paperwork Reduction Project (1660-0058). NOTE: Do not send your completed form to the above address.
1. APPLICANT (Political subdivision of eligible applicant)                                           2. DATE SUBMITTED

3. COUNTY (Location of firefighting activities. If located in multiple counties, please indicate.)

                                                      APPLICANT PHYSICAL LOCATION

2. CITY                                                3. County                                     4. STATE       5. ZIP CODE

                                         MAILING ADDRESS (If different from Physical Location)

2. POST OFFICE BOX                                     3. CITY                                       4. STATE       5. ZIP CODE

           Primary Contact/Applicant’s Authorized Agent                                              Alternate Contact
1. NAME                                                                     1. NAME

2. TITLE                                                                    2. TITLE

3. BUSINESS PHONE                                                           3. BUSINESS PHONE

4. FAX NUMBER                                                               4. FAX NUMBER

5. HOME PHONE                                                               5. HOME PHONE

6. CELL PHONE                                                               6. CELL PHONE

7. E-MAIL ADDRESS                                                           7. E-MAIL ADDRESS

8. PAGER & PIN NUMBER                                                       8. PAGER & PIN NUMBER

Title 44 CFR Part 204.41 defines Fire Management Assistance eligibility criteria as: (a) The following entities are eligible to apply through
a State grantee for a subgrant under an approved fire management assistance grant: 1) State agencies; 2) Local governments; and 3)
Indian Tribal Governments. (b) Entities that are not eligible to apply for a subgrant as identified in (a), such as privately owned entities
and volunteer firefighting organizations, may be reimbursed through a contract or compact with an eligible applicant for eligible cost
associated with the fire or fire complex. (c) Eligibility is contingent upon the finding that the applicant’s resources were requested by the
Incident Commander or comparable State official. (d) The activities performed must be the legal responsibility of the applying entity,
required as a result of the fire or fire complex for which a fire management assistance declaration was approved, and located within the
declared 90-133,
FEMA Formarea. JUL 05                                   PREVIOUS EDITION OBSOLETE

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