FEMA FMAGP APPLICANT FORMS
EXCEL 97 FORMAT
ALL SHEETS ARE PRINTABLE
Note: Only the blocks in Yellow need to be filled out. White boxes are automatically filled from previous sheets.
U. S. DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY
O.M.B. NO. 1660-0058 Expires July 31, 2008
REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION
PAPERWORK BURDEN DISCLOSURE NOTICE
DISCLOSURE OF BURDEN-Public reporting burden for the collection of information entitled "Request for Fire Management Assistance Declaration" using FEMA Form 90-58 is estimated to average 1 hour per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and financial resources expended by persons, and completing and submitting the form. You are not required to complete this collection of information unless a valid OMB control numbers appears in the upper right corner on this form. Send comments regarding the burden estimate or any aspect of the collection, including 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 (3067-0290). NOTE: Do not send your completed form to the above address.
1. STATE 2. DATE OF REQUEST 3. TIME OF REQUEST
4. NAME OF GOVERNOR OR AUTHORIZED REPRESENTATIVE
PHONE NO. INCLUDING AREA CODE a. Day b. Night
5. AGENCY REPRESENTED
ADDRESS (Street, City, Zip)
NOTE: In making this request, the Government agrees to abide by provisions contained in FEMA-State Agreement for Fire Management Assistance under Section 420, Pl 93-288 as amended. This request must be signed below by the Governor personally or by his authorized representative, whom he has previously authorized to sign this request in the FEMA-State Agreement. 6. SIGNATURE TITLE DATE
I. EXISTING CONDITIONS 7. EXISTENCE OF HIGH FIRE DANGER CONDITIONS 8. NUMBER OF WILD FIRES a. CONTROLLED ACRES BURNED b. UNCONTROLLED # ACRES BURNED d. PREVAILING WEATHER CONDITIONS AND PREDICTIONS FOR NEXT 24 HOURS a. TEMPERATURE b. RELATIVE HUMIDITY c. DIRECTION AND VELOCITY OF WINDS
c. EXISTENCE OF OTHER FIRES NEARBY WHICH LIMITS THE COMMITMENT OF STATE FIRE FIGHTING RESOURCES d. EXISTENCE OF OTHER FIRES NEARBY THAT MAY RESULT IN A CONFLAGRATION 9. INDICES: NATIONAL FIRE DANGER RATING SYSTEM OTHER (KBDI, SPI, HAINES, PALMER, ETC.) #
10. STATE & LOCAL BURN BANS: 11. NATIONAL WATCHES: YES NO WARNINGS YES NO YES NO
II. FIRE SITUATION REPORT 12. TIME OF REPORT 13. NAME OF UNCONTROLLED FIRE 14. DATE STARTED
15. LOCATION OF UNCONTROLLED FIRE: (County)
16. ACRES BURNING: a. FEDERAL
%
b. STATE
%
c. PRIVATE
%
17. MANPOWER AND RESOURCES COMMITTED (Attach separate sheet if necessary) STATE: LOCAL:
18. TYPE AND AMOUNT OF FEDERAL OR OTHER ASSETS & RESOURCES NEEDED: (FEMA does not order resources)
FEMA Form 90-58, MAR 05 [M/S Excel]
REPLACES ALL PREVIOUS EDITIONS
III. CURRENT THREAT 19. THREAT TO LIFE a. PREPARATIONS MADE FOR EVACUATION? YES NO ADDITIONAL INFORMATION b. PERSONS EVACUATED:
#
20. NAME AND LOCATION OF COMMUNITY THREATENED CITY TOWN
#
SUBDIVISION
21. CASUALTIES: 1. CIVILIAN LOSS OF LIFE 2. CIVILIANS INJURED 3. FIRE FIGHTERS LOSS OF LIFE 4. FIRE FIGHTERS INJURED 23. THREAT TO FACILITIES (Include number when applicable) AMOUNT BUILDINGS ROADS & BRIDGES INFRASTRUCTURE UTILITIES ADDITIONAL INFORMATION TYPE
22. THREAT TO PRIVATE PROPERTY: (Dwellings) 1. NUMBER OF HOMES
a. % OF PRIMARY
b. % OF SECONDARY
AMOUNT RECREATION EQUIPMENT BUSINESS OTHER
TYPE
24. THREAT TO RESOURCES WATERSHED IRRIGATION FLOOD CONTROL FISHING STREAMS & SPAWNING SITES ADDITIONAL INFORMATION WILDLIFE (Type threatened, fur-bearing animals, big game, etc.) ENVIRONMENTAL RESOURCES (bio-diverse areas, etc.) CULTURAL RESOURCES ECONOMIC INJURY
IV. STATE ASSESSMENT 25. EMERGENCY MANAGEMENT ASSESSMENT OF THE SITUATION
SIGNATURE 26. FORESTRY ASSESSMENT OF THE SITUATION
DATE
SIGNATURE FEMA REGIONAL USE ONLY 27. NAME OF PERSON WHO RECEIVED OFFICIAL REQUEST TITLE
DATE
DATE
Request for Fire Management Assistance Declaration Instructions 1. Enter name of State 2. Enter date of request 3. Enter time of request 4. Enter name of Governor or Authorized Representative, including day and night time phone numbers and area codes 5. Enter Agency Representative, including address (street, city, zip 6. Enter signature, including title and date 7. Existence of high fire danger conditions 7a. Enter temperature 7b. Enter relative humidity 7c. Enter direction and velocity of winds 7d. Enter prevailiing weather conditions and predictions for next 24 hours 8. Number of wild fires 8a. Enter number of controlled wild fires and number of acres burned 8b. Enter number of uncontrolled wild fires and number of acres burned 8c. Enter number of the existence of other fires nearby which limit the commitment of State fire fighting resources 8d. Enter the number of the existence of other fires nearby that may result in a conflagaration 9. Indices: select either the box indicating the use of the National Fire Danger Rating System or the box indicating the use of Other indices (KBDI, SPI, Haines, Palmer, Etc. 10. State & Local Burn Bans: select either the box indicating yes or no 11. National Watches: select either the box indicating yes or no Warnings select either the box indicating yes or no 12. Enter time of report 13. Enter name of controlled fire 14. Enter date started 15 Enter locatio of uncontrolled fire (county) 16. Acres Burned 16a. Enter percentage of Federal acres burned 16b. Enter percentage of State acres burned 16c. Enter percentage of private acres burned 17. Enter State and Local manpower and resources committed (attach separate sheet if necessary) 18. Enter type and amount of Federal or other assets and resources needed (FEMA does not order resources) 19. Enter threat to life in numbers 19a. Answer the question: Preparations made for evacaution? By selecting either the box indicating yes or no 19b. Enter the number of persons evacuated 20. Enter the name and locations of community threatened, including city, town, subdivision, and additional information 21. Enter the number of casualties: (in the following areas) 1. Civilian loss of life 2. Civilians injured 3. Fire fighters loss of life 4. Fire fighters injured
22. Enter the threat to private property: (in the following areas) 1. Number of homes a. Percentage of primary homes b. Percentage of secondary homes 23. Enter the threat to facilities (include number when applicaple in the following areas) Buildings: amount and type Roads and Bridges: amount and type Infrastructure: amount and type Utilities: amount and type Recreation: amount and type Equipment: amount and type Business: amount and type Other: amount and type Additional information 24. Enter the threat to resources (select the boxes that apply) Watershed Irrigation Flood control Fishing streams and spawning sites Wildlife (type threatened, fur-bearing animals, big game, etc.) Environmental resources (bio-diverse areas, etc.) Cultural resources Economic injury Additional information 25. Enter Emergency Management assessment of the situation, include signature and date 26. Enter Forestry assessment of the situation, include signature and date 27. Enter name of person who received the official request (For FEMA Regional use only), include title and date
APPLICATION FOR FEDERAL ASSISTANCE
1. TYPE OF SUBMISSION:
OMB Approval No. 0348-0043
2. DATE SUBMITTED
Applicant Identifier
3. DATE RECEIVED BY STATE
State Application Identifier
Application Construction Non-Construction
5. APPLICANT INFORMATION
Preapplication Construction Non-Construction
4. DATE RECEIVED BY FEDERAL AGENCY
Federal Identifier
Legal Name: Address (give city, county, state, and zip code):
Organizational Unit: Name and telephone number of person to be contacted on matters involving this application (give area code)
6. EMPLOYER IDENTIFICATION NUMBER (EIN):
7. TYPE OF APPLICANT: (enter appropriate letter in box)
A. State
8. TYPE OF APPLICATION:
H. Independent School Dist. I. State Controlled Institution of Higher Learning J. Private University K. Indian Tribe L. Individual M. Profit Organization N. Other (Specify)
B. County New Continuation Revision C. Municipal D. Township E. Interstate F. Intermunicipal C. Increase Duration G. Special District
9. NAME OF FEDERAL AGENCY:
If Revision, enter appropriate letter(s) in box(es) A. Increase Award D. Decrease Duration B. Decrease Award Other (specify):
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
TITLE: 12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):
13. PROPOSED PROJECT:
14. CONGRESSIONAL DISTRICTS OF:
Start Date
Ending Date
a. Applicant
b. Project
15. ESTIMATED FUNDING:
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
a. Federal b. Applicant c. State d. Local e. Other f. Program Income
g. TOTAL
$ $ $ $ $ $ $
ORDER 12372 PROCESS?
a. YES.
THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:
0
0 0 .00
Yes
b. NO.
DATE:
PROGRAM IS NOT COVERED BY E.O. 12372 OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
If "Yes," attach an explanation
No
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. Type Name of Authorized Representative
b. Title
c. Telephone Number
d. Signature of Authorized Representative
e. Date Signed
Previous Edition Usable Authorized for Local Reproduction
Standard Form 424 (REV. 4-92) Prescribed by OMB Circular A-102
FEDERAL EMERGENCY MANAGEMENT AGENCY
REQUEST FOR FIRE MANAGEMENT ASSISTANCE SUBGRANT
PAPERWORK BURDEN DISCLOSURE NOTICE
O.M.B. NO. 3067-0290 Expires July 31, 2008
DISCLOSURE OF BURDEN-Public reporting burden for the collection of information entitled “Request for Fire Management Assistance Declaration” using FEMA Form 90-133 is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data and financial resources expended by persons, and completing and submitting the form. You are not required to complete this collection of information unless a valid OMB control number appears in the upper right hand corner on this form. Send comments regarding the burden estimate or any aspect of the collection, including suggestions for reducing the burden, to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, D.C. 20472, Paperwork Reduction Project (3067-0290). NOTE: Do not send your completed form to the above address.
1. APPLICANT (Political subdivision or eligible applicant) Example - Washington 3. COUNTY (location of firefighting activities. If located in multiple counties, please indicate) Example - Elma APPLICANT PHYSICAL LOCATION FEMA
2. DATE SUBMITTED
2. CITY
3. COUNTY
4. STATE
5. ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL LOCATION) 1. STREET ADDRESS
2. POST OFFICE BOX
3. CITY
4. STATE
5. ZIP CODE
Primary Contact/Applicant’s Authorized Agent 1. NAME 2. TITLE 1. NAME 2. TITLE
Alternate Contact
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 8. PAGER & PIN NUMBER
7. E-MAIL ADDRESS 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 area. FEMA Form 90-133, NOV 02
FEDERAL EMERGENCY MANAGEMENT AGENCY PROJECT WORKSHEET
O.M.B. No. 3067-0151 Expires July 31, 2008
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 90 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears 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, Federal Emergency Management Agency, 500 C Street SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). Submission of the form is required to obtain benefits under the Public Assistance Program. NOTE: Do not send your completed form to the above address.
DISASTER FEMA -XXXX -DR - XX DAMAGED FACILITY
PROJECT NO.
PA ID NO. 000-00000-00
DATE
CATEGORY H
WORK COMPLETE AS OF ________ : ________ % COUNTY Example - Elma LATITUDE LONGITUDE
APPLICANT Example - Washington LOCATION Example - 12 miles Northeast of Elma DAMAGE DESCRIPTION AND DIMENSIONS
SCOPE OF WORK
Does the Scope of Work change the pre-disaster conditions at the site? Special Considerations included?
Yes No Yes No
Yes
No Yes No
Hazard Mitigation proposal included? PROJECT COST
Is there insurance coverage on this facility? ITEM CODE
NARRATIVE
QUANTITY
UNIT
UNIT PRICE
COST $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL COST PREPARED BY APPLICANT REP.
FEMA Form 90-91, OCT 02
$0.00
TITLE TITLE
REPLACES ALL PREVIOUS EDITIONS.
SIGNATURE SIGNATURE
PROJECT WORKSHEET INSTRUCTIONS The Project Worksheet must be completed for each identified damaged project. A project may include damages more than one site. After completing all Project Worksheets, submit the worksheets to your Public Assistance Coordinator. Identifying Information Disaster: Indicate the disaster declaration number as established by FEMA (i.e. "FEMA 1136-DR-TN", etc.). Project No: Indicate the project designation number you established to track the project in your system (i.e. 1,2,3, etc.). PA ID No.: Indicate your Public Assistance identification number on this space. This is optional. Date: Indicate the date the worksheet was prepared in MM/DD/YY format. Category: Indicate the category of the project according to FEMA specified work categories (i.e.,A,B,C,D,E,F,G). This is optional. Applicant: Name of the government or other legal entity to which the funds will be awarded. County: Name of the county where the damaged facility is located. If located in multiple counties, indicate "Multi-County." Damage Facility: Identify the facility and describe its basic function and pre-disaster condition. Work Complete as of: Indicate the date the work was assessed in the format of MM/DD/YY and the percentage of work completed to that date. Location: This item can range anywhere from an "address," intersection of…," "1 mile south of …on…" to "county wide." If damages are in different locations or different counties please list each location. Include latitude and longitude of the project if known. Damage Description and Dimensions: Describe the disaster-related damage to the facility, including the cause of the damage and the area or components affected. Scope of Work: List work that has been completed, and work to be completed, which, is necessary to repair disaster-related damage. Does the Scope of Work change the pre-disaster conditions of the site: If the work described under the Scope of Work changes the site conditions (i.e. increases/decreases the size or function of the facility or does not replace damage components in kind with like materials), check (x) yes. If the Scope of Work returns the site to its pre-disaster configuration, capacity and dimensions check (x) no. Special Considerations: If the project includes insurable work, and/or is affected by environmental (NEPA) or historic concerns, check (x) either the Yes or No box so that appropriate action can be initiated to avoid delays in funding. Refer to Applicant Handbook for further information. Hazard Mitigation: If the pre-disaster conditions at the site can be changed to prevent or reduce the disaster-related damage, check (x) Yes. If no opportunities for hazard mitigation exist check (x) no. Appropriate action will be initiated and avoid delays in funding. Refer to Applicant Handbook for further information. Is there insurance coverage on this facility: Federal law requires that FEMA be notified of any entitlement for proceeds to repair disaster-related damages from insurance or any other source. Check (x) yes if any funding or proceeds can be received for the work within the Scope of Work from any source besides FEMA. Project Cost Item: Indicate the item number on the column (i.e. 1, 2, 3, etc.). Use additional forms as necessary to include all items. Code: If using the FEMA cost codes, place the appropriate number here. Narrative: Indicate the work, material or service that best describes the work (i.e. "force account labor overtime", "42 in. RCP", "drywall replacement", etc.). Quantity/Unit: List the amount of units and the unit of measure (48/cy", "32/lf', "6/ea", etc.). Unit Price: Indicate the price per unit. Cost: This item can be developed from cost to date, contracts, bids, applicant's experience in that particular repair work, books which lend themselves to work estimates, such as RS Means, or by using cost codes supplied by FEMA. Total Cost: Record total cost of the project. Prepared By: Record the name, title, and signature of the person completing the Project Worksheet. Applicant Rep.: Record the name, title, and signature of Applicant's representative. Records Requirements Please review the Applicant Handbook, FEMA 323 for detailed instructions and examples. For all completed work, the applicant must keep the following records: *Force account labor documentation sheets identifying the employee, hours worked, date and location; *Force account equipment documentation sheets identifying specific equipment, operator, usage by hour/mile and cost used; *Material documentation sheets identifying the type of material, quantity used and costs; *Copies of all contracts for work and any lease/rental equipment costs. For all estimated work, keep calculations, quantity estimates, pricing information, etc. as part of the records to document the "cost/estimate" for which funding is being requested.
FEDERAL EMERGENCY MANAGEMENT AGENCY DISASTER FEMA ___ APPLICANT Example - Washington - DR ______ COUNTY PROJECT WORKSHEET - Maps and Sketches Sheet PROJECT NO. PA ID NO. DATE
O.M.B. No. 3067-0151 Expires July 31, 2008
CATEGORY
H
FEMA Form 90-91C, OCT 02
FEDERAL EMERGENCY MANAGEMENT AGENCY SPECIAL CONSIDERATION QUESTION APPLICANT'S NAME PROJECT NAME LOCATION Form must be filled out - for each project.
1.
O.M.B. No. 3067-0151 Expires October 31, 2008
DATE
Does the damaged facility or item of work have insurance and/or is it an insurable risk? (e.g., buildings, equipment, vehicles, etc.) Yes No Unsure Comments
2.
Is the damaged facility located within a floodplain or coastal high hazard area/or does it have an impact on a floodplain or wetland? Yes No Unsure Comments
3.
Is the damaged facility or item of work located within or adjacent to a Coastal Barrier Resource System Unit or an Otherwise Protected Area? Yes No Unsure Comments
4.
Will the proposed facility repairs/reconstruction change the pre-disaster condition? (e.g., footprint, material, location, capacity, use or function) Yes No Unsure Comments
5.
Does the applicant have a hazard mitigation proposal or would the applicant like technical assistance for a hazard mitigation proposal? Yes No Unsure Comments
6.
Is the damaged facility on the National Register of Historic Places or the state historic listing? Is it older than 50 years? Are there other, similar buildings near the site? Yes No Unsure Comments
7.
Are there any pristine or undisturbed areas on, or near, the project site? Are there large tracts of forestland? Yes No Unsure Comments
8.
Are there any hazardous materials at or adjacent to the damaged facility and/or item of work? Yes No Unsure Comments
9.
Are there any other environmentally or controversial issues associated with the damaged facility and/or item of work? Yes No Unsure Comments
FEMA Form 90-120, FEB 06
FEDERAL EMERGENCY MANAGEMENT AGENCY
FORCE ACCOUNT LABOR SUMMARY RECORD
APPLICANT Example - Washington LOCATION/SITE Example - 12 miles Northeast of Elma DESCRIPTION OF WORK PERFORMED PA ID NO. 000-00000-00 CATEGORY PROJECT NO.
PAGE ____ OF ____
O.M.B. No 3067-0151 Expires October 31, 2008
DISASTER PERIOD COVERING TO
H
Dates and Hours Worked Each Week DATE NAME REG. JOB TITLE O.T. NAME REG. JOB TITLE O.T. NAME REG. JOB TITLE O.T. NAME REG. JOB TITLE O.T. NAME REG. JOB TITLE O.T. NAME REG. JOB TITLE O.T. TOTAL HOURS HOURLY RATE
Costs BENEFIT RATE/HR TOTAL HOURLY RATE TOTAL COSTS
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL COST FOR FORCE ACCOUNT LABOR REGULAR TIME TOTAL COST FOR FORCE ACCOUNT LABOR OVERTIME
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
CERTIFY THAT THE ABOVE INFORMATION WAS OBTAINED FROM PAYROLL RECORDS, INVOICES, OR OTHER DOCUMENTS THAT ARE AVAILABLE FOR AUDIT. CERTIFIED TITLE DATE
FEMA Form 90-123, OCT
PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to 30 minutes per response. The burden includes the time for reviewing instruction, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). Submission of the form is required to obtain or retain benefits under the Public Assistance Program. Please do not send your completed form to the above address.
FORCE ACCOUNT LABOR SUMMARY RECORD INSTRUCTIONS
Force account is the term used to define labor performed and equipment owned by the applicant.
•► •► •► Record regular and overtime hours separately. Record the benefits separately for regular and overtime hours. Most overtime hours include fewer benefits than regular hours. Attach a Fringe Benefit Rate Sheet giving a breakdown of what is included in your benefits, by percentages, e.g., social security----15.2%, worker's compensation----4.3%, insurance----18.5%, etc. You can use an average rate if you have different benefit rates for different employees.
Complete the Record as Follows: * * * * * * * * Applicant: Enter organization's name. PA ID No.: Enter the computer tracking number that FEMA assigns to applicant organization. Your Public Assistance Coordinator can provide you with this number. Project No.: Enter the number assigned to this project. Disaster: Enter the declaration number for this disaster. The Public Assistance Coordinator can also provide you with this information. Location/Site: This item can range anywhere from an "address," intersection of…/" "1 mile south of …on…" to "county wide." If damages are in different locations or different counties please list each location. Include latitude and longitude of the project if known. Category: Indicate the category of the project according to FEMA specified work categories (i.e., B, H, Z). This is optional. Period Covering: This is auto filled from the "Dates & Hours Worked Each Week / Date." Description of Work Performed: Describe the type of work performed. Dates & Hours Used Each Week / Date: Enter the days of the week. Name: Enter the names of each employee who worked on the project. Job Title: Enter the title or occupation of each employee who worked on the project. REG: Enter the regular hours that each employee worked on the project. O.T.: Enter overtime hours that each employee worked on the project. REMINDER: Only overtime is eligible for reimbursement for emergency work. Record both regular and overtime hours, so that personnel hours can be compared with equipment use hours, if necessary. Costs / Total Hours: Calculates the total hours for the week and auto fills "Total Hours" block. Costs / Hourly Rate: Enter each employee's hourly rate. Costs / Benefit Rate/Hr: Enter each employee's hourly benefit rate. Their should be different percentages for benefits pertaining to regular and overtime wages. Costs / Total Hourly Rate: Excel will add the employee's hourly rate in the "Hourly Rate" block and the hourly benefits rate in the "Benefit Rate/HR" block and auto fills "Total Hourly Rate" block. Costs / Total Cost: Multiply the entries in the "Total Hrs" and "Total Hourly Rate" blocks and auto fills "Total Costs" block. Total Cost for Force Account Labor Regular Time: Add the entries in the "Total Costs", "REG" block for each employee and the results in the "Total Cost for Force Account Labor Regular Time" block. Total Cost for Force Account Labor Overtime: Add the entries in the "Total Costs", "O.T." block for each employee and the results in the "Total Cost for Force Account Labor Overtime" block. Certified: Record the name, title, and date of the person certifying the Force Account Labor Summary Record.
* * * * *
* * * * * * * *
updated 5/6/05
3a99be51-4d6f-4aa2-8417-f27e30f104a1.xls, 8
FEDERAL EMERGENCY MANAGEMENT AGENCY
MATERIAL SUMMARY SHEET
APPLICANT PA ID NO. PROJECT NO.
Page ____ OF ______
O.M.B. No. 3067-0151 Expires October 31, 2008
DISASTER
Example - Washington
LOCATION/SITE CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma
DESCRIPTION OF WORK PERFORMED
TO
VENDOR
DESCRIPTION
QUAN.
UNIT PRICE
TOTAL PRICE
DATE PURCHASED
DATE USED
INFO FROM (CHECK ONE) INVOICE STOCK
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GRAND TOTAL $0.00
I CERTIFY THAT THE ABOVE INFORMATION WAS OBTAINED FROM PAYROLL RECORDS, INVOICES, OR OTHER DOCUMENTS THAT ARE AVAILABLE FOR AUDIT. CERTIFIED TITLE DATE
FEMA Form 90-124, OCT 02
PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to 15 minutes per response. The burden includes the time for reviewing instruction, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). Submission of the form is required to obtain or retain benefits under the Public Assistance Program. Please do not send your completed form to the above address.
THE MATERIAL RECORD SUMMARY INSTRUCTIONS
This form is used to record the costs of supplies and materials purchased in response to the disaster or used to repair damages caused by the disaster. Complete the Record as Follows:
* * * * *
Applicant: Enter organization's name. PA ID No.: Enter the computer tracking number that FEMA assigns to applicant organization. Your Public Assistance Coordinator can provide you with this number. Project No.: Enter the number assigned to this project. Disaster: Enter the declaration number for this disaster. The Public Assistance Coordinator can also provide you with this information. Location/Site: This item can range from an "address," "intersection of…," "1 mile south of…on…" to "county wide." If damages are in different locations or different counties please list each location. Include latitude and longitude of the project if known. Category: Indicate the category of the project according to FEMA specified work categories (i.e., B, H, Z). This is optional. Period Covering: Enter the dates that this period covers. Description of Work Performed: Describe the type of work that was performed.
* * * * * * * * * * * * *
Vendor: Enter the name of the supplier if the material was bought specifically as a result of the disaster.
Description: Enter a brief description of the supplies or materials used or purchased. Quan.: Enter the number purchased. Unit Price: Enter the price per unit. Total Price: Calculates the "Quan." times the "Unit Price" and auto fills "Total Price" block. Date Purchased: Enter the date item was purchased. Date Used: Enter the date item was used. Info. from (Check One) Invoice or Stock: Place a check (√) in either the "Invoice" or "Stock" block. Grand Total: Adds the costs from "Total Price" blocks and auto fills "Grant Total" block. Certified: Record the name, title, and date of the person certifying the Material Summary Record.
Updated 5/6/05
3a99be51-4d6f-4aa2-8417-f27e30f104a1.xls, 10
FEDERAL EMERGENCY MANAGEMENT AGENCY
RENTED EQUIPMENT SUMMARY RECORD
APPLICANT PA ID NO. PROJECT NO.
PAGE ____ OF _____ DISASTER
O.M.B. No. 3067-0151 Expires October 31, 2008
Example - Washington
LOCATION/SITE
000-00000-00
CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma
DESCRIPTION OF WORK PERFORMED
H
TO
TYPE OF EQUIPMENT Indicate size, Capacity, Horsepower, Make and Models as Appropriate
DATES AND HOURS USED
RATE PER HOUR W/OPR W/OUT OPR TOTAL COST VENDOR INVOICE NO. DATE AND AMOUNT PAID CHECK NO.
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
GRAND TOTAL
$0.00
I CERTIFY THAT THE ABOVE INFORMATION WAS OBTAINED FROM PAYROLL RECORDS, INVOICES, OR OTHER DOCUMENTS THAT ARE AVAILABLE FOR AUDIT.
CERTIFIED
TITLE
DATE
FEMA Form 90-125, OCT 02
PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to 15 minutes per response. The burden includes the time for reviewing instruction, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). Submission of the form is required to obtain or retain benefits under the Public Assistance Program. Please do not send your completed form to the above address.
RENTED EQUIPMENT SUMMARY RECORD INSTRUCTIONS This form is used to record the costs of equipment that rented or leased to respond to the disaster or be used in making repairs to damages caused by the disaster. Complete the Record as Follows:
* * * * *
Applicant: Enter your organization's name. PA ID No.: Enter the computer tracking number that FEMA assigns to applicant organization. Your Public Assistance Coordinator can provide you with this number. Project No.: Enter the number assigned to this project. Disaster: Enter the declaration number for this disaster here. The Public Assistance Coordinator can also provide you with this information. Location/Site: This item can range from an "address," "intersection of…," "1 mile south of…on…" to "county wide." If damages are in different locations or different counties please list each location. Include latitude and longitude of the project if known. Category: Indicate the category of the project according to FEMA specified work categories (i.e., B, H, Z). This is optional. Period Covering: Enter the dates that this period covers. Type of Equipment: Enter a brief description of the equipment that was leased or rented. Indicate if the equipment was rented on a daily, weekly, or monthly rate, instead of an hourly rate. Date and Hours Used: Enter the dates for each day the project was worked in the top box and the hours the equipment was used in the bottom box. Rate Per Hour With or Without Operator: Enter the hourly rental or lease cost of the equipment with or without operator. NOTE: Determine that the rental rate is fair and reasonable and has not been raised to an unacceptable rate because of the disaster. Total Cost: Multiplies the entries in the second box under "Dates & Hours Used" and times it by the "Rate Per Hour - W/OPR or W/OUT OPR" and auto fills "Total Cost" block. Vendor: Enter the name of the vendor. Invoice No.: Enter the invoice number. Date & Amount Paid: Enter the date of invoice in the top box and the usage cost based on the renter's agreement in the bottom box. Check No.: Enter the check number. Grand Total: Calculates the "Total Cost" blocks and auto fills the "Grand Total" block. Certified: Record the name, title, and date of the person certifying the Rent Equipment Summary Record.
* * * * *
* * * * * * *
Updated 5/6/05
3a99be51-4d6f-4aa2-8417-f27e30f104a1.xls, 12
FEDERAL EMERGENCY MANAGEMENT AGENCY
CONTRACT WORK SUMMARY RECORD
APPLICANT PA ID NO. PROJECT NO. CATEGORY
PAGE ____ OF _____
DISASTER
O.M.B. No. 3067-0151 Expires October 31, 2008
Example - Washington
LOCATION/SITE PERIOD COVERING
Example - 12 miles Northeast of Elma
DESCRIPTION OF WORK PERFORMED
H
TO
DATES WORKED
CONTRACTOR
BILLING/INVOICE NUMBER
AMOUNT
COMMENTS - SCOPE
GRAND TOTAL
$0.00
I CERTIFY THAT THE ABOVE INFORMATION WAS OBTAINED FROM PAYROLL RECORDS, INVOICES, OR OTHER DOCUMENTS THAT ARE AVAILABLE FOR AUDIT. CERTIFIED TITLE DATE
FEMA Form 90-126, OCT 02
PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to 15 minutes per response. The burden includes the time for reviewing instruction, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). Submission of the form is required to obtain or retain benefits under the Public Assistance Program. Please do not send your completed form to the above address.
CONTRACT WORK SUMMARY RECORD INSTRUCTIONS This form is used to record the costs of contracts awarded to respond to the disaster. Complete the Record as Follows: * * Applicant: Enter organization's name. PA ID No.: Enter the computer tracking number that FEMA assigns to applicant organization. Your Public Assistance Coordinator can provide you with this number. Project No.: Enter the number assigned to this project. Disaster: Enter the declaration number for this disaster here. The Public Assistance Coordinator can also provide you with this information.
Location/Site: This item can range from an "address," "intersection of…," "1 mile south of…on…" to "county wide." If damages are in different locations or different counties please list each location. Include latitude and longitude of the project if known.
* *
*
* * * * * * * * * *
Category: Indicate the category of the project according to FEMA specified work categories (i.e., B, H, Z). This is optional. Period Covering: Enter the dates that this period covers. Description of Work Performed: Enter a brief description of the work performed. Date Worked: Enter the date on the invoice. Contractor: Enter the name of the contractor receiving the contract. Billing/Invoice Number: Enter the invoice number. Amount: Enter the total dollar figure listed for each invoice. Comments - Scope: Enter a brief description of the type of work that was performed on each invoice. Grand Total: Calculates the "Amount" blocks and auto fills the "Grand Total" block. Certified: Record the name, title, and date of the person certifying the Contract Work Summary Record.
Updated 5/6/05
3a99be51-4d6f-4aa2-8417-f27e30f104a1.xls, 14
FEDERAL EMERGENCY MANAGEMENT AGENCY FORCE ACCOUNT EQUIPMENT SUMMARY RECORD APPLICANT PA ID NO.
O.M.B. No. 3067-0151 PAGE PROJECT NO. ___ OF ______ Expires October 31, 2008 DISASTER
Example - Washington
LOCATION/SITE CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma
DESCRIPTION OF WORK PERFORMED
H
TO
Type of Equipment INDICATE SIZE, CAPACITY, HORSEPOWER, MAKE AND MODEL AS APPROPRIATE EQUIPMENT CODE NUMBER OPERATOR'S NAME DATE
Dates and Hours Used Each Day TOTAL HOURS
Costs EQUIPMENT RATE TOTAL COST
Hours 0.0 Hours 0.0 Hours 0.0 Hours 0.0 Hours 0.0 Hours 0.0 Hours 0.0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
GRAND TOTALS
0.0
I CERTIFY THAT THE ABOVE INFORMATION WAS OBTAINED FROM PAYROLL RECORDS, INVOICES, OR OTHER DOCUMENTS THAT ARE AVAILABLE FOR AUDIT. CERTIFIED TITLE DATE
FEMA Form 90-127, OCT 02
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to 15 minutes per response. The burden includes the time for reviewing instruction, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). Submission of the form is required to obtain or retain benefits under the Public Assistance Program. Please do not send your completed form to the above address.
FORCE ACCOUNT EQUIPMENT SUMMARY RECORD INSTRUCTIONS
Force account is the term used to define labor performed and equipment owned by the applicant. Complete the Record as Follows: * Applicant: Enter organization's name. * PA ID No.: Enter the computer tracking number that FEMA assigns applicant organization. Your Public Assistance Coordinator can provide you with this number. * Project No.: Enter the number assigned to this project. * Disaster: Enter the declaration number for this disaster here. The Public Assistance Coordinator can also provide you with this information. * Location/Site: This item can range anywhere from an "address," intersection of…/" "1 mile south of …on…" to "county wide." If damages are in different locations or different counties please list each location. Include latitude and longitude of the project if known. * Category: Indicate the category of the project according to FEMA specified work categories (i.e., B, H, Z). This is optional. * Period Covering: It's auto filled from "Dates & Hours Used Each Day / Date" blocks. * Description of Work Performed: Describe the type of work performed. * Type of Equipment / Indicate size, capacity, horsepower, make and model as appropriate: Enter a brief description of the equipment, including the rated horsepower or capacity of the equipment. Be sure to include this information if you also use a trade name or common name to describe the equipment, e.g., Ditch Witch. * Equipment Code Number: Enter the FEMA cost code for the equipment. * Operator's Name: Enter the equipment operators name. * Dates & Hours Used Each Day / Date: Enter the days of the week. * Hours: Enter the hours the equipment worked. Notes: Standby time for equipment is not eligible. * Costs / Total Hours: Adds the total hours for the week and auto fills the Total Hours block. * Costs / Equipment Rate: Enter the hourly rate for the equipment. * Costs / Total Cost: Multiply the number in the Total Hours block by the number in the Equipment Rate block and auto fills the amount in the Total Cost block. * Grand Totals: Add the numbers in the Total Hours blocks and auto fills into the Grand Total block; Add the numbers in the Total Cost blocks and auto fills into the Grand Total block. * Certified: Record the name, title, and date of the person certifying the Force Account Equipment Summary Record.
Updated 5/6/05
3a99be51-4d6f-4aa2-8417-f27e30f104a1.xls, 16
FEDERAL EMERGENCY MANAGEMENT AGENCY
APPLICANT'S BENEFITS CALCULATION WORKSHEET
APPLICANT
PAGE ____ OF ____
O.M.B. No. 3067-0151 Expires October 31, 2008
PA ID NO.
Example - Washington
DISASTER PROJECT NO.
FRINGE BENEFITS (by %) HOLIDAYS VACATION LEAVE SICK LEAVE SOCIAL SECURITY MEDICARE UNEMPLOYMENT WORKER'S COMP. RETIREMENT HEALTH BENEFITS LIFE INS. BENEFITS OTHER TOTAL in % of annual salary COMMENTS
REGULAR TIME
OVERTIME
3.8% 5.8% 4.6% 7.7% 7.7%
1.5% 2.0% 5.5% 23.3% 1.2%
1.5% 2.0% 5.5%
55.3%
16.6%
I CERTIFY THAT THE INFORMATION ABOVE WAS TRANSCRIBED FROM PAYROLL RECORDS OR OTHER DOCUMENTS WHICH ARE AVAILABLE
CERTIFIED BY
TITLE
DATE
FEMA Form 90-128, OCT 02
PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to 30 minutes per response. The burden includes the time for reviewing instruction, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). Submission of the form is required to obtain or retain benefits under the Public Assistance Program. Please do not send your completed form to the above address.
Fringe Benefit Calculations
There are other ways to calculate Fringe Benefits, this is only one. This is normally done for each employee or each pay grade.
Employee Name: Applicant: PA ID No: Disaster Number: Department:
All calculations are based on the amount that only the employer pays . Most figures can be obtained from accounting department.
Blocks that you fill in = Work hrs per year (2080 hrs is normal work year ) Pay / Hour Basic Pay Annualized # $ $ 2,080 20.00 41,600.00 Regular Time 120.00 80.00 96.00 5.45 7.65 1.50 2.00 23.08 1.15 0.14 0.09 % 5.8 3.8 4.6 5.5 7.7 1.5 2.0 23.1 1.2 0.1 0.1 See note 1 Overtime * * * 5.45 7.65 1.50 2.00 * * * * * * %
Vacation - days/year Holidays - days/year Sick - days/year Retirement (% of annual salary) Social Security - fixed rate Unemployment Workman’s Comp Health Insurance Life Insurance Dental Vision
# # # ) % % % $ $ $ $ %
15 10 12 5.45 7.65 1.50 2.00 800.00 40.00 5.00 3.00
days days days
5.5 7.7 1.5 2.0
/ mo / employee / mo / employee / mo / employee / mo / employee
Total Percent = Transfer to Data Sheet for Employee Starting at row F35 Typical ranges I certify that the information above was transcribed from payroll records or other documents which are available for audit. Certified by: ________________________________________ Title: ______________________________________________
55.3
16.6
20-60 %
3-20 %
Note 1: Vacation, Holidays and Insurance are not figured into overtime benefits. 401K plans or similar type plans sometimes are not included in Overtime. Retirement, Unemployment and Workman's Comp are sometimes included in overtime benefits.
updated 5/6/05
3a99be51-4d6f-4aa2-8417-f27e30f104a1.xls, Fringe Benefits
FRINGE BENEFIT RATE SHEET INSTRUCTIONS Fringe Benefit Calculations
Fringe benefits for force account labor is eligible. Except in extremely unusual cases, fringe benefits for overtime will be significantly less than regular time. The following steps will assist in calculating the percentage of fringe benefits paid on an employee's salary. Note: items and percentages will vary from one entity to another.
1) The normal year consists of 2080 hours (52 weeks x 5 workdays/week x 8 hours/day). This does not include holidays
and vacations.
2) Determine the employee's basic hourly pay rate (annual salary/2080 hours). 3) Fringe benefit percentage for vacation time: Divide the number of hours of annual vacation time provided to the 4) 5) 6) 7) 8)
employee by 2080 (80 hours (2 weeks)/2080 = 3.85%). Fringe benefit percentage for paid holidays: Divide the number of paid holiday hours by 2080 (64 hours (8 holidays)/2080 = 3.07%). Retirement pay: Because this measure varies widely, use only the percentage of salary matched by the employer. Social Security and Unemployment Insurance: Both are standard percentages of salary. Insurance: This benefit varies by employee. Divide the amount paid by the city or county by the basic pay rate determined in Step 2. Workman's Compensation: This benefit also varies by employee. Divide the amount paid by the city or county by the basic pay rate determined in Step 2. Use the rate per $100 to determine the correct percentage. Note: Typically, you should not be charging the same rate for regular time and overtime. Generally, only FICA (Social Security) is eligible for overtime; however, some entities may charge retirement tax on all income. Sample Rates Although some rates may differ greatly between organizations due to their particular experiences, the table below provides some general guidelines that can be used as a reasonableness test to review submitted claims. These rates are based on experience in developing fringe rates for several state departments, the default rate is that used for the state of Florida, following Hurricane Andrew (August 1992), and the review of several FEMA claims. The rates presented are determined using the gross wage method applicable to the personnel hourly rate (PHR) method. The net available hours method would result in higher rates. Paid Fringe Benefits HCA Matching Retirement--Regular Retirement--Special Risk Health Insurance Life & Disability Insurance Worker's Compensation Unemployment Insurance Leave Fringe Benefits Accrued Annual Leave Sick Leave Administrative Leave Holiday Leave Compensatory Leave
7.65% 17.00% 25.00% 12.00% 1.00% 3.00% 0.25% 7.00% 4.00% 0.50% 4.00% 2.00%
(or slightly less) (or less) (or slightly more) (or less) (or less) (or less) (or less) (or less) (or less) (or less) (or less) (or less)
Rates outside of these ranges are possible, but should be justified during the validation process.
updated 5/6/05
3a99be51-4d6f-4aa2-8417-f27e30f104a1.xls, 19
FEDERAL EMERGENCY MANAGEMENT AGENCY
See Reverse for Instructions and Paperwork Burden Disclosure Notice Page ___ of ___ pages
OMB NO. 3067-0206
Expires February 28, 2007
FINANCIAL STATUS REPORT
1. FEDERAL AGENCY AND ORGANIZATIONAL ELEMENT TO WHICH REPORT IS SUBMITTED 4. EMPLOYER I.D. NO.
ASSIGNED
2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
5. RECIPIENT ACCT. NO. OR I.D. 6. FINAL REPORT
7. BASE CASH ACCRUAL
8. Funding/Grant Period From: To:
9. Period Covered This Report
YES NO STATUS OF REPORT 10. PROGRAM ACRONYM CFDA NUMBER a. Net Outlays b. Recipient share of outlays c. Federal share of outlays d. Total unliquidated obligations e. Recipient share of unliquidated obligations f. Federal share of unliquidated obligations g. Total Federal share (Sum of line c and line f) h. Total Federal funds authorized for this funding period i. Unobligated balance of Federal funds (Line h minus line g) (a) (b) (c)
From: To:
(d)
(e)
TOTAL
COMPUTATION OF TOTAL INDIRECT COST EXPENSE AS REPORTED ON LINES 10a TO 10g 11a. Type of indirect cost rate (Place x in the appropriate box) b. Indirect cost rate c. Base d. Total Amount of Indirect cost e. Federal share of indirect cost 12. REMARKS: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation. Provisional-Final Predetermined Fixed with carry forward
13. CERTIFICATION: I certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and unliquidated obligations are for the purposes set forth in the award document. TYPE OR PRINT NAME AND TITLE FEMA Form 20-10, MAR 01 SIGNATURE OF AUTHORIZED REPRESENTATIVE TELEPHONE NO. (Include area code, and extension) DATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
SUMMARY SHEET FOR ASSURANCES AND CERTIFICATIONS
DATE: APPLICANT LEGAL NAME:
O.M.B. No. 3067-02006 Expires September 30, 1998
This summary sheet includes Assurances and Certifications that must be read, signed, and submitted as a part of the Application for Federal Assistance. An applicant must check each item that they are certifying to:
Part I Part II Part III
FEMA Form 20-16A, Assurances-Nonconstruction Programs FEMA Form 20-16B, Assurances-Construction Programs FEMA Form 20-16C, Certifications Regarding Lobbying; Debarment, Suspension, and Other Responsibility Matters; and Drug-Free Workplace Requirements SF LLL, Disclosure of Lobbying Activities (If applicable)
Part IV
As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the identified attached assurances and certifications.
Typed Name of Authorized Representative
Title
Signature of Authorized Representative
Date Signed
NOTE: By signing the certification regarding debarment, suspension, and other responsibility matters for primary covered transaction, the applicant agrees that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by FEMA entering into this transaction. The applicant further agrees by submitting this application that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction," provided by the FEMA Regional Office entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. (Refer to 44 CFR Part 17.) Paperwork Burden Disclosure Notice
"Public reporting burden for this form is estimated to average 1.7 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing, reviewing, and maintaining the data needed, and completing and submitting the form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472."
FEMA Form 20-16, JUL 95
FEDERAL EMERGENCY MANAGEMENT AGENCY
ASSURANCES-NON-CONSTRUCTION PROGRAMS Note: Certain of these assurances may not be applicable to your project or program. If you have any 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 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 U.S.C. 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 C.F.R. 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 (P.L. 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 U.S.C. 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 U.S.C. Section 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. Sections 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 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 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of
FEMA Form 20-16A, JUN 94
alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 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 Acts of 1968 (42 U.S.C. 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 Title II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 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 interest in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply with provisions of the Hatch Act (5 U.S.C. 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. 9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. Sections 276a to 276a7), the Copeland Act (40 U.S.C. Section 276c and 18 U.S.C. Sections 874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. Sections 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 (P.L. 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 U.S.C. 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 U.S.C. Section 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205). 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 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 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
14. Will comply with P.L. 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 (P.L. 89-544, as amended, 7 U.S.C. 2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 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 U.S.C. 201), as they apply to employees of institutions of higher education, hospitals, and other non-profit organizations.
FEMA Form 20-16A (BACK)
FEDERAL EMERGENCY MANAGEMENT AGENCY
ASSURANCES-CONSTRUCTION PROGRAMS NOTE: Certain of these assurances may not be applicable to your project or program. If you have any 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 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 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 U.S.C. Sections 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 C.F.R. 900, Subpart F).
FEMA Form 20-16B, JUN 94
9. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. Sections 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 non-discrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 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 U.S.C. 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 U.S.C. Section 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. Sections 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to non-discrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to non-discrimination on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 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 Acts of 1968 (42 U.S.C. Section 3601 et seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (i) any other non-discrimination provision in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other non-discrimination statute(s) which may apply to the application. 11. Will comply, or has already complied, with the requirements of Title II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 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 interest in real property acquired for project purposes regardless of Federal participation in purchase. 12. Will comply with provisions of the Hatch Act (5 U.S.C. 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 U.S.C. Sections 276a to 276a-7), the Copeland Act (40 U.S.C. Section 276c and 18 U.S.C. Section 874), the Contract Work Hours and Safety Standards Act (40 U.S.C. Sections 327-333) regarding labor standards for federally assisted construction subagreements. 14. Will comply with the 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. 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 (P.L. 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 U.S.C. 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 U.S.C. Section 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205). 16. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 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 U.S.C. 470), EO 11593 (identification and preservation of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 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 hours provisions of the Federal Fair Labor Standards Act (29 U.S.C. 201), as they apply to employees of institutions of higher education, hospitals, and other non-profit 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 Specifications 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 Non-profit Organizations" included in Vol. 49, Federal Register, pages 18260 through 18277 (April 27, 1984).
FEMA Form 20-16B (BACK)
FEDERAL EMERGENCY MANAGEMENT AGENCY
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS 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 (Nonprocurement) 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 section 1352, Title 31 of the U.S. 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 the 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 an employee of Congress, or 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; (c) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subgrants, contracts under grants and cooperative agreements, and subcontract(s) and that all subrecipients shall certify and disclose accordingly. Standard Form LLL, "Disclosure of Lobbying Activities" attached. (This form must be attached to certification if nonappropriated funds are to be used to influence activities.) (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 tht will be taken against employees for violation of such prohibition; (b) Establishing an on-going drug free awareness program to 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; FEMA Form 20-16C, JUN 94 (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; inform empoyees about: A. The applicant certifies that it will continue to privide a drugfree workplace by: B. Where the applicant is unable to certify to any of the statements in this certification, he or shall shall attached an explanation to this application. (d) Have not within a three-year period preceding this application had one or more public t ransactions (Federal, State, or local) terminated for cause or default; and (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and (b) Have not within a three-year period preceding this application been convicted of ar 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;
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 17.620:
2. DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS (DIRECT RECIPIENT)
(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) 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). 8. the grantee may insert in the space provided below the site(s) for
(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.
the performance of work done in connection with the specific grant: Place of Performance (Street address, City, County, State, Zip code)
Check (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
if there are workplaces on file that are not identified here.
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.
FEMA Form 20-16C (BACK)
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure) 1. Type of Federal Action: a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: Prime Subawardee Tier , if known: 2. Status of Federal Action: a. bid/offer/application b. initial award c. post-award 3. Report Type: a. initial filing b. material change
Approved by OMB 0348-0046
For Material Change Only: year date of last report 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime: quarter
Congressional District, if known: 6. Federal Department/Agency:
Congressional District, if known: 7. Federal Program Name/Description:
CFDA Number, if applicable: 8. Federal Action Number, if known: 9. Award Amount, if known: $ 10. a. Name and Address of Lobbying Registrant (if individual, last name, first name, MI): b. Individuals Performing Services (including address if different from No. 10a) (last name, first name, MI):
16.
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 information 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. Telephone No.: Date: Title: Print Name: Signature:
Federal Use Only:
Authorized for Local Reproduction Standard Form - LLL
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Personnel
Page 1 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
12. (a) (b) (c) (d) (e)
POSITION TITLE
POSITION NUMBER
POSITION TYPE
HIRE
DATE VACANCY
Comments:
Page 1 of 10 pages
CHECK POINT
TOTAL STATE & FEDERAL PERSONNEL FROM WORKSHEET TOTAL STATE & FEDERAL PERSONNEL FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
ddress, including zip code)
Enter Grant Number in Box 2 above
#REF!
(i) (f) (g) (h)
(j)
(k)
% OF SALARY
DATE OF SALARY INCREASE
WORK YEARS
ANNUAL SALARY
TOTAL STATE & FEDERAL SAL. 83.534 SLA 100
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.534 SLA 50
% OF SALARY
TOTAL STATE & FEDERAL SAL.
0.000
0.00
0.00
0.00
0.00
(l)
(m)
(n)
(o)
(p)
% OF SALARY
TOTAL STATE & FEDERAL SAL.
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.011 SARA
% OF SALARY
TOTAL STATE & FEDERAL SAL.
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.505 DPIG
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.550 NDSP
0.00
0.00
0.00
0.00
0.00
(q)
(r)
(s)
(t)
(u)
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.105 CAP-SSSE
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.535 MAP
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.536 FMA PL
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.536 FMA TA
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.549 CSEPP O&M
0.00
0.00
0.00
0.00
0.00
(v)
(w)
% OF SALARY
TOTAL STATE & FEDERAL SAL. 83.549 CSEPP PROC
% OF SALARY Non-Federal
0.00
0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Personnel 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task 12a.Enter position title 12b.Enter position number 12c.Enter position type 12d.Enter hire date 12e.Enter vacancy date 12f.Enter date of salary increase 12g.Enter work years 12h.Enter annual salary 12i.Enter percent of salary and total State and Federal salary (SLA 100) 12j.Enter percent of salary and total State and Federal salary (SLA 50) 12k.Enter percent of salary and total State and Federal salary 12l.Enter percent of salary and total State and Federal salary 12m.Enter percent of salary and total State and Federal salary (SARA) 12n.Enter percent of salary and total State and Federal salary 12o.Enter percent of salary and total State and Federal salary (DPIG) 12p.Enter percent of salary and total State and Federal salary (NDSP) 12q.Enter percent of salary and total State and Federal salary (CAP-SSSE) 12r.Enter percent of salary and total State and Federal salary (MAP) 12s.Enter percent of salary and total State and Federal salary (FMA PL) 12t.Enter percent of salary and total State and Federal salary (FMA TA) 12u.Enter percent of salary and total State and Federal salary (CSEPP O&M) 12v.Enter percent of salary and total State and Federal salary (CSEPP PROC) 12w.Enter percent of salary and total State and Federal salary (Non-Fedreal) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Fringe Benefits
Page 2 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
OPTION #1
12. (a) (b) (c)
83.534 SLA 100 0.00
83.534 SLA 50 0.00 0.00 0.00
TOTAL SALARY PERCENTAGE APPLIED FRINGE BENEFITS
OPTION #2
13. (a)
(b) AMOUNT
DESCRIPTION
(c) 83.534 SLA 100
(d) 83.534 SLA 50
0.00 TOTAL
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
Comments:
Page 2 of 10 pages
CHECK POINT
TOTAL FRINGE BENEFITS FROM WORKSHEET TOTAL FRINGE BENEFITS FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
ddress, including zip code)
Enter Grant Number in Box 2 above
#REF!
(f)
(g)
(h)
(i)
(j)
(k)
(l)
83.011 SARA 0.00 0.00
83.505 DPIG 0.00
83.550 NDSP 0.00
83.105 CAP-SSSE 0.00
83.535 MAP 0.00
83.536 FMA PL 0.00
(g)
(h)
(i)
(j)
(k)
(l)
(m)
83.011 SARA
83.505 DPIG
83.550 NDSP
83.105 CAP-SSSE
83.535 MAP
83.536 FMA PL
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
(m)
(n)
(o)
(p)
83.536 FMA TA 0.00
83.549 CSEPP O&M 0.00
83.549 CSEPP PROC 0.00
Non-Federal 0.00
(n)
(o)
(p)
(q)
83.536 FMA TA
83.549 CSEPP O&M
83.549 CSEPP PROC
0.00 0.00
0.00 0.00
0.00 0.00
Non-Federal 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Fringe Benefits 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task Option #1 12a.Enter total salary, percentage applied and fringe benefits 12b.Enter percent of salary and total State and Federal salary (SLA 100) 12c.Enter percent of salary and total State and Federal salary (SLA 50) 12d.Enter percent of salary and total State and Federal salary 12e.Enter percent of salary and total State and Federal salary 12f.Enter percent of salary and total State and Federal salary (SARA) 12g.Enter percent of salary and total State and Federal salary 12h.Enter percent of salary and total State and Federal salary (DPIG) 12i.Enter percent of salary and total State and Federal salary (NDSP) 12j.Enter percent of salary and total State and Federal salary (CAP-SSSE) 12k.Enter percent of salary and total State and Federal salary (MAP) 12l.Enter percent of salary and total State and Federal salary (FMA PL) 12m.Enter percent of salary and total State and Federal salary (FMA TA) 12n.Enter percent of salary and total State and Federal salary (CSEPP O&M) 12o.Enter percent of salary and total State and Federal salary (CSEPP PROC) 12p.Enter percent of salary and total State and Federal salary (Non-Federal) Option #2 13a.Enter description 13b.Enter amount 13c.Enter percent of salary and total State and Federal salary (SLA 100) 13d.Enter percent of salary and total State and Federal salary (SLA 50) 13e.Enter percent of salary and total State and Federal salary 13f.Enter percent of salary and total State and Federal salary 13g.Enter percent of salary and total State and Federal salary (SARA) 13h.Enter percent of salary and total State and Federal salary 13i.Enter percent of salary and total State and Federal salary (DPIG) 13j.Enter percent of salary and total State and Federal salary (NDSP) 13k.Enter percent of salary and total State and Federal salary (CAP-SSSE) 13l.Enter percent of salary and total State and Federal salary (MAP) 13m.Enter percent of salary and total State and Federal salary (FMA PL) 13n.Enter percent of salary and total State and Federal salary (FMA TA) 13o.Enter percent of salary and total State and Federal salary (CSEPP O&M) 13p.Enter percent of salary and total State and Federal salary (CSEPP PROC) 13q.Enter percent of salary and total State and Federal salary (Non-Federal) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Travel
Page 3 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
12. (a)
TOTAL
(b) (c)
MILEAGE
(c X d X e) = (d) (e) (f)
DESCRIPTION OF TRAVEL
TOTAL NUMBER OF TRAVELERS
NUMBER OF TRAVELERS
NUMBER OF MILEAGE MILES/TRAVELER RATE
TOTAL MILEAGE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Comments:
Page 3 of 10 pages
CHECK POINT
TOTAL TRAVEL FROM WORKSHEET TOTAL TRAVEL FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
ddress, including zip code)
Enter Grant Number in Box 2 above
#REF!
TAXI / LIMO
(g X h) = (g) (h) (i) (j)
AIRFARE
(j X k) = (k) (l) (m)
PER D
NUMBER OF TRAVELERS
TAXI LIMO PER TRAVELER
TOTAL TAXI LIMO 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
NUMBER OF TRAVELERS
AIRFARE PER TRAVELER
TOTAL AIRFARE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
NUMBER OF TRAVELERS
PER DIEM
(m X n X o) = (n) (o) (p) (q)
MISCELLANEOUS
(q X r) = (r) (s)
TOTAL
(f + i + l + p + s) = (t) (u)
PER DIEM
NUMBER OF DAYS PER TRAVELER
TOTAL PER DIEM 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
NUMBER OF TRAVELERS
MISC COSTS PER TRAVELER
TOTAL MISC COSTS 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TOTAL COST 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
PRIORITY
(v)
(w)
(x)
(y)
(z)
(aa)
(ab)
(ac)
(ad)
TRAVEL COSTS 83.534 SLA 100
TRAVEL COSTS 83.534 SLA 50
TRAVEL COSTS
TRAVEL COSTS
TRAVEL COSTS 83.011 SARA
TRAVEL COSTS
TRAVEL COSTS 83.505 DPIG
TRAVEL COSTS 83.550 NDSP
TRAVEL COSTS 83.105 CAP-SSSE
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
(ae)
(af)
(ag)
(ah)
(ai)
TRAVEL COSTS 83.535 MAP
TRAVEL COSTS 83.536 FMA PL
TRAVEL COSTS 83.536 FMA TA
TRAVEL COSTS 83.549 CSEPP O&M
TRAVEL COSTS 83.549 CSEPP PROC
(v thru ai) = (aj) TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
(t - aj) = (ak) DIFFERENCE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Travel 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task 12a.Enter description of travel Total 12b.Enter total number of travelers 12c.Enter number of travelers Mileage 12d.Enter number of miles per traveler 12e.Enter mileage rate 12f.Enter total mileage ((c x d x e) = f) 12g.Enter number of travelers Taxi/Limo 12h.Enter taxi limo per traveler 12i.Enter total taxi limo ((g x h) = i) Airfare 12j.Enter number of travelers 12k.Enter airfare per traveler 12l.Enter total airfare ((j x k) = l) Per Diem 12m.Enter number of travelers 12n.Enter per diem 12o.Enter number of days per traveler 12p.Enter total per diem ((m x n x o) = p) Miscellaneous 12q.Enter number of travelers 12r.Enter miscellaneous costs per traveler 12s.Enter total miscellaneous costs ((q x r) = s) Total 12t.Enter total cost ((f + i + l + p + s) = t) 12u.Enter priority 12v.Enter travel costs (SLA 100) 12w.Enter travel costs (SLA 50) 12x.Enter travel costs 12v.Enter travel costs 12z.Enter travel costs (SARA) 12aa.Enter travel costs 12ab.Enter travel costs (DPIG) 12ac.Enter travel costs (NDSP) 12ad.Enter travel costs (CAP-SSSE) 12ae.Enter travel costs (MAP) 12af.Enter travel costs (FMA PL) 12ag.Enter travel costs (FMA TA) 12ah.Enter travel costs (CSEPP O&M) 12ai.Enter travel costs (CSEPP PROC)
Enter total ((v thru ai) = aj) Enter difference ((t - aj) = ak) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Equipment
Page 4 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
12. (b X c) = (a) (b) (c) (d) (e)
(f)
DESCRIPTION OF EQUIPMENT
UNIT COST
QUANTITY
TOTAL COST 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
PRIORITY
EQUIPMENT COSTS 83.534 SLA 100
0.00
Comments:
Page 4 of 10 pages
CHECK POINT
TOTAL EQUIPMENT COSTS FROM WORKSHEET TOTAL EQUIPMENT COSTS FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
ddress, including zip code)
Enter Grant Number in Box 2 above
#REF!
(g)
(h)
(i)
(j)
(k)
(l)
(m)
EQUIPMENT COSTS 83.534 SLA 50
EQUIPMENT COSTS
EQUIPMENT COSTS
EQUIPMENT COSTS 83.011 SARA
EQUIPMENT COSTS
EQUIPMENT COSTS 83.505 DPIG
EQUIPMENT COSTS 83.550 NDSP
0.00
0.00
0.00
0.00
0.00
0.00
0.00
(n)
(o)
(p)
(q)
(r)
(s)
EQUIPMENT COSTS 83.105 CAP-SSSE
EQUIPMENT COSTS 83.535 MAP
EQUIPMENT COSTS 83.536 FMA PL
EQUIPMENT COSTS 83.536 FMA TA
EQUIPMENT COSTS 83.549 CSEPP O&M
EQUIPMENT COSTS 83.549 CSEPP PROC
(f thru s) = (t) TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
(d - t) = (u) DIFFERENCE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Equipment 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task 12a.Enter description of equipment 12b.Enter unit cost 12c.Enter quantity 12d.Enter total cost ((b x c) = d) 12e.Enter priority 12f.Enter equipment costs (SLA 100) 12g.Enter equipment costs (SLA 50) 12h.Enter equipment costs 12i.Enter equipment costs 12j.Enter equipment costs (SARA) 12k.Enter equipment costs 12l.Enter equipment costs (DPIG) 12m.Enter equipment costs (NDSP) 12n.Enter equipment costs (CAP-SSSE) 12o.Enter equipment costs (MAP) 12p.Enter equipment costs (FMA PL) 12q.Enter equipment costs (FMA TA) 12r.Enter equipment costs (CSEPP O&M) 12s.Enter equipment costs (CSEPP PROC) Enter total ((f thru s) = t) Enter difference ((d - t) = u) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Supplies
Page 5 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
12. (b X c) = (a) (b) (c) (d) (e)
DESCRIPTION OF SUPPLIES
UNIT COST
QUANTITY
UNIT DESCRIPTION
TOTAL COST 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Comments:
Page 5 of 10 pages
CHECK POINT
TOTAL SUPPLY COSTS FROM WORKSHEET TOTAL SUPPLY COSTS FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
ddress, including zip code)
Enter Grant Number in Box 2 above
#REF!
(g) (f)
(h)
(i)
(j)
(k)
(l)
PRIORITY
SUPPLY COSTS 83.534 SLA 100
SUPPLY COSTS 83.534 SLA 50
SUPPLY COSTS
SUPPLY COSTS
SUPPLY COSTS 83.011 SARA
SUPPLY COSTS
0.00
0.00
0.00
0.00
0.00
0.00
(m)
(n)
(o)
(p)
(q)
(r)
(s)
(t)
SUPPLY COSTS 83.505 DPIG
SUPPLY COSTS 83.550 NDSP
SUPPLY COSTS 83.105 CAP-SSSE
SUPPLY COSTS 83.535 MAP
SUPPLY COSTS 83.536 FMA PL
SUPPLY COSTS 83.536 FMA TA
SUPPLY COSTS 83.549 CSEPP O&M
SUPPLY COSTS 83.549 CSEPP PROC
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
(g thru t) = (u)
(e - u) = (v)
TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
DIFFERENCE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Supplies 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task 12a.Enter description of supplies 12b.Enter unit cost 12c.Enter quantity 12d.Enter unit description 12e.Enter total cost ((b x c) = e) 12f.Enter priority 12g.Enter supplies costs (SLA 100) 12h.Enter supplies costs (SLA 50) 12i.Enter supplies costs 12j.Enter supplies costs 12k.Enter supplies costs (SARA) 12l.Enter supplies costs 12m.Enter supplies costs (DPIG) 12n.Enter supplies costs (NDSP) 12o.Enter supplies costs (CAP-SSSE) 12p.Enter supplies costs (MAP) 12q.Enter supplies costs (FMA PL) 12r.Enter supplies costs (FMA TA) 12s.Enter supplies costs (CSEPP O&M) 12t.Enter supplies costs (CSEPP PROC) Enter total ((g thru t) = u) Enter difference ((e - u) = v) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Contractual
Page 6 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
12. (b X c) = (a) (b) (c) (d) (e)
NARRATIVE DESCRIPTION
UNIT COST
QUANTITY
UNIT DESCRIPTION
TOTAL COST 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Comments:
Page 6 of 10 pages
CHECK POINT
TOTAL CONTRACTUAL COSTS FROM WORKSHEET TOTAL CONTRACTUAL COSTS FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
ddress, including zip code)
Enter Grant Number in Box 2 above
#REF!
(g) (f)
(h)
(i)
(j)
(k)
(l)
PRIORITY
CONTRACTUAL COSTS 83.534 SLA 100
CONTRACTUAL COSTS 83.534 SLA 50
CONTRACTUAL COSTS
CONTRACTUAL COSTS
CONTRACTUAL COSTS 83.011 SARA
CONTRACTUAL COSTS
0.00
0.00
0.00
0.00
0.00
0.00
(m)
(n)
(o)
(p)
(q)
(r)
(s)
(t)
CONTRACTUAL COSTS 83.505 DPIG
CONTRACTUAL COSTS 83.550 NDSP
CONTRACTUAL COSTS 83.105 CAP-SSSE
CONTRACTUAL COSTS 83.535 MAP
CONTRACTUAL COSTS 83.536 FMA PL
CONTRACTUAL COSTS 83.536 FMA TA
CONTRACTUAL COSTS 83.549 CSEPP O&M
CONTRACTUAL COSTS 83.549 CSEPP PROC
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
(g thru t) = (u)
(e - u) = (v)
TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
DIFFERENCE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Contractual 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task 12a.Enter narrative description 12b.Enter unit cost 12c.Enter quantity 12d.Enter unit description 12e.Enter total cost ((b x c) = e) 12f.Enter priority 12g.Enter contractual costs (SLA 100) 12h.Enter contractual costs (SLA 50) 12i.Enter contractual costs 12j.Enter contractual costs 12k.Enter contractual costs (SARA) 12l.Enter contractual costs 12m.Enter contractual costs (DPIG) 12n.Enter contractual costs (NDSP) 12o.Enter contractual costs (CAP-SSSE) 12p.Enter contractual costs (MAP) 12q.Enter contractual costs (FMA PL) 12r.Enter contractual costs (FMA TA) 12s.Enter contractual costs (CSEPP O&M) 12t.Enter contractual costs (CSEPP PROC) Enter total ((g thru t) = u) Enter difference ((e - u) = v) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
SLA Counties
Page 7 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
A.
B. (State or Local Organization)
C. (1)
NUMBER OF PAID PERSONNEL
(1 + 2) = (2) (3)
TEN
NAME OF APPLICANT
FULL TIME
PART TIME
TOTAL
GRAND TOTAL
0
0
Page 7 of 10 pages
CHECK POINT
TOTAL SLA COUNTIES COSTS FROM WORKSHEET TOTAL SLA COUNTIES COSTS FROM FEMA FORM 20-20 DIFFERENCE 0.00
ddress, including zip code)
0.00
Enter Grant Number in Box 2 above
0.00
ERSONNEL
(1 + 2) = (3) (4)
WORK YEARS
(4 + 5) = (5) (6)
D.
DIRECTOR PAID OTHER
E. (1)
TOTAL ESTIMATED EXPENS
(2)
TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
PROFESSIONAL
CLERICAL
TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
SLA PAID
VOLUNTEER
PERSONNEL
TRAVEL
0.00
0.00
0.00
0.00
0.00
STIMATED EXPENSES
(1 + 2 + 3) = (3) (4)
ALL OTHER
TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00
0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Contractual 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task A. Enter ten B. Enter name of applicant C. Number of paid personnel C1.Enter number of full time paid personnel C2.Enter number of part time paid personnel C3.Enter total number of paid personnel ((1 + 2) = 3) C. Work Years C4.Enter professional personnel C5.Enter clerical personnel C6.Enter total work years ((4 + 5) = 6) D. Director Enter SLA Paid Enter Paid Other Enter Volunteer E.Total Estimated Expenses E1.Enter Personnel E2.Enter Travel E3.Enter All Other E4.Enter Total ((1 + 2 + 3) = 4) Enter Grant Total
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Construction
Page 8 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
Revised Budget. Enter Grant Number in Box 2 above
12. (a) (b) (c)
(d)
(e)
NARATIVE DESCRIPTION
TOTAL COST
PRIORITY
CONSTRUCTION COSTS 83.534 SLA 100
CONSTRUCTION COSTS 83.534 SLA 50
0.00 Comments:
0.00
0.00
Page 8 of 10 pages
CHECK POINT
TOTAL CONSTRUCTION COSTS FROM WORKSHEET TOTAL CONSTRUCTION COSTS FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
ddress, including zip code)
Enter Grant Number in Box 2 above
#REF!
(f)
(g)
(h)
(i)
(j)
(k)
(l)
CONSTRUCTION COSTS
CONSTRUCTION COSTS
CONSTRUCTION COSTS 83.011 SARA
CONSTRUCTION COSTS
CONSTRUCTION COSTS 83.505 DPIG
CONSTRUCTION COSTS 83.550 NDSP
CONSTRUCTION COSTS 83.105 CAP-SSSE
0.00
0.00
0.00
0.00
0.00
0.00
0.00
(m)
(n)
(o)
(p)
(q)
CONSTRUCTION COSTS 83.535 MAP
CONSTRUCTION COSTS 83.536 FMA PL
CONSTRUCTION COSTS 83.536 FMA TA
CONSTRUCTION COSTS 83.549 CSEPP O&M
CONSTRUCTION COSTS 83.549 CSEPP PROC
(d thru q) = (r)
(b - r) = (s)
TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
DIFFERENCE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Construction 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task 12a.Enter narrative description 12d.Enter total cost 12e.Enter priority 12d.Enter construction costs (SLA 100) 12e.Enter construction costs (SLA 50) 12f.Enter construction costs 12g.Enter construction costs 12h.Enter construction costs (SARA) 12i.Enter construction costs 12j.Enter construction costs (DPIG) 12k.Enter construction costs (NDSP) 12l.Enter construction costs (CAP-SSSE) 12m.Enter construction costs (MAP) 12n.Enter construction costs (FMA PL) 12o.Enter construction costs (FMA TA) 12p.Enter construction costs (CSEPP O&M) 12q.Enter construction costs (CSEPP PROC) Enter total ((d thru q) = r) Enter difference ((b - r) = s) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Other
Page 9 of 10 pages
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Revised Budget. Enter Grant Number in Box 2 above Date of Budget Revision: 11. TASK:
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
12. (b X c) = (a) (b) (c) (d) (e) (f)
NARRATIVE DESCRIPTION
UNIT COST
QUANTITY
UNIT DESCRIPTION
TOTAL COST 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
PRIORITY
Comments:
CHECK POINT
TOTAL OTHER COSTS FROM WORKSHEET TOTAL OTHER COSTS FROM FEMA FORMS 20-20 DIFFERENCE #REF! 0.00
#REF!
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
OTHER COSTS 83.534 SLA 100
OTHER COSTS 83.534 SLA 50
OTHER COSTS
OTHER COSTS
OTHER COSTS 83.011 SARA
OTHER COSTS
OTHER COSTS 83.505 DPIG
OTHER COSTS 83.550 NDSP
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
(o)
(p)
(q)
(r)
(s)
(t)
OTHER COSTS 83.105 CAP-SSSE
OTHER COSTS 83.535 MAP
OTHER COSTS 83.536 FMA PL
OTHER COSTS 83.536 FMA TA
OTHER COSTS 83.549 CSEPP O&M
OTHER COSTS 83.549 CSEPP PROC
(g thru t) = (u)
(e - u) = (v)
TOTAL 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
DIFFERENCE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Other 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task 12a.Enter narrative description 12b.Enter unit cost 12c.Enter quantity 12d.Enter unit description 12e.Enter total cost ((b x c) = e) 12f.Enter priority 12g.Enter other costs (SLA 100) 12h.Enter other costs (SLA 50) 12i.Enter other costs 12j.Enter other costs 12k.Enter other costs (SARA) 12l.Enter other costs 12m.Enter other costs (DPIG) 12n.Enter other costs (NDSP) 12o.Enter other costs (CAP-SSSE) 12p.Enter other costs (MAP) 12q.Enter other costs (FMA PL) 12r.Enter other costs (FMA TA) 12s.Enter other costs (CSEPP O&M) 12t.Enter other costs (CSEPP PROC) Enter total ((g thru t) = u) Enter difference ((e - u) = v) Enter comments
of budget revision)
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
OBJECT CLASS CATEGORY:
Indirect Costs
Page 10 of 10 pages
CHECK POINT
TOTAL INDIRECT COSTS FROM WORKSHEET #REF!
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Revised Budget. Enter Grant Number in Box 2 above Date of Budget Revision: 11. TASK:
TOTAL INDIRECT COSTS FROM FEMA FORMS 20-20 DIFFERENCE
#REF!
Beginning Date: Ending Date: 8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY:
#REF!
OPTION #1
12. (a) (b) (c) (d) (e) (f) (g) (h) (i) (j)
EFFECTIVE PERIOD OF RATE AGREEMENT
TOTAL PERSONNEL NEGOTIATED & FRINGE BENEFITS RATE #REF!
INDIRECT COSTS CLAIMED #REF!
83.534 SLA 100 TOTAL PERSONNEL & FRINGE BENEFITS NEGOTIATED RATE INDIRECT COSTS CLAIMED 0.00
83.534 SLA 50 0.00 0.00 0.00
83.011 SARA #REF!
0.00
0.00
0.00
0.00
#REF!
OPTION #2
13. (a) (b) (c) (d) (e) (f) (g) (h)
EFFECTIVE PERIOD OF RATE AGREEMENT
COMMENTS TOTAL DIRECT CHARGES LESS LESS LESS TOTAL NEGOTIATED RATE INDIRECT COSTS CLAIMED #REF! #REF!
83.534 SLA 100 0.00
83.534 SLA 50 0.00 0.00 0.00
83.011 SARA #REF!
#REF!
0.00
0.00
0.00
0.00
#REF!
0.00
0.00
0.00
0.00
#REF!
OPTION #3
14. (a) (b) (c) (d) (e) (f) (g) (h)
EFFECTIVE PERIOD OF RATE AGREEMENT
COMMENTS BASE NEGOTIATED RATE INDIRECT COSTS CLAIMED BASE NEGOTIATED RATE INDIRECT COSTS CLAIMED BASE NEGOTIATED RATE INDIRECT COSTS CLAIMED 0.00 0.00 0.00
83.534 SLA 100
83.534 SLA 50
83.011 SARA
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
TOTAL INDIRECT COSTS CLAIMED TOTAL STATE & FEDERAL INDIRECT COSTS CLAIMED
0.00 #REF!
0.00
0.00
0.00
#REF!
(k)
(l)
(m)
(n)
(o)
(p)
(q)
(r)
(s)
(t)
#REF!
83.505 DPIG #REF!
83.550 NDSP #REF!
83.105 CAP-SSSE #REF!
83.535 MAP #REF!
83.536 FMA PL #REF!
83.536 FMA TA #REF!
83.549 CSEPP O&M #REF!
83.549 CSEPP PROC #REF!
Non-Federal 0.00
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
0.00
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
(q)
#REF!
83.505 DPIG #REF!
83.550 NDSP #REF!
83.105 CAP-SSSE #REF!
83.535 MAP #REF!
83.536 FMA PL #REF!
83.536 FMA TA #REF!
83.549 CSEPP O&M #REF!
83.549 CSEPP PROC #REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
(d thru q) = (i) (j) (k) (l) (m) (n) (o) (p) (q) (r) (s)
(c - s) = (t)
83.505 DPIG
83.550 NDSP
83.105 CAP-SSSE
83.535 MAP
83.536 FMA PL
83.536 FMA TA
83.549 CSEPP O&M
83.549 CSEPP PROC
Non-Federal
TOTAL 0.00
DIFFERENCE 0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
#REF!
0.00
Instructions for Worksheet for Budget Narrative Nonconstruction Programs Object Class Category: Indirect Costs 1. Enter Program Agency and Organization element to which report is submitted 2. Enter Federal Grant or other assigned identifying number 3. Enter Recipient Organizatin (name and complete address, including zip code 4. Enter Employer Identification 5. Enter Recipient account number or identification number 6. Enter beginning and ending dates of budget period (month, day, year) 7. Select either the New Budget box or the Revised Budget box (enter date of budget revision) 8. Enter program and CFDA numbers 9. Enter function 10.Enter activity 11.Enter task Option #1 12a.Enter effective period of rate agreement 12b.Enter total personnel and fringe benefits 12c.Enter negotiated rated 12d.Enter indirect costs claimed 12e.Total personnel and fringe benefits negotiated rate and indirect costs claimed 12f.Enter SLA 100 12g.Enter SLA 50 12h. 12i. 12j.Enter SARA 12k. 12l.Enter DPIG 12m.Enter NDSP 12n.Enter CAP-SSSE 12o.Enter MAP 12p.Enter FMA PL 12q.Enter FMA TA 12r.Enter CSEPP O&M 12s.Enter CSEPP PROC 12t.Enter Non-Federal Option #2 13a.Enter effective period of rate agreement 13b.Enter comments 13c.Enter total direct charges (less), total, negotiated rate, and indirect costs claimed 13d.Enter SLA 100 13e.Enter SLA 50 13f. 13g. 13h.Enter SARA 13i. 13j.Enter DPIG 13k.Enter NDSP 13l.Enter CAP-SSSE 13m.Enter MAP 13n.Enter FMA PL 13o.Enter FMA TA 13p.Enter CSEPP O&M 13q.Enter CSEPP PROC Option #3 14a.Enter effective period of rate agreement 14b.Enter comments
14c.Enter base, negotiated rate, and indirect costs claimed 14d.Enter SLA 100 14e.Enter SLA 50 14f. 14g. 14h.Enter SARA 14i. 14j.Enter DPIG 14k.Enter NDSP 14l.Enter CAP-SSSE 14m.Enter MAP 14n.Enter FMA PL 14o.Enter FMA TA 14p.Enter CSEPP O&M 14q.Enter CSEPP PROC 14r.Enter Non-Federal 14s.Enter total ((d thru q) = s) 14t.Enter difference ((c - s) = t) Enter total indirect costs claimed Enter total State and Federal indirect costs claimed
of budget revision)
t costs claimed
FEDERAL EMERGENCY MANAGEMENT AGENCY
See reverse for Paperwork Burden Disclosure Notice Page of pages
OMB No. 3067-0206 Expires February 28, 2007
BUDGET INFORMATION--NONCONSTRUCTION PROGRAMS
1. PROGRAM AGENCY AND ORGANIZATION ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED
3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
4. EMPLOYER IDENTIFICATION
5. RECIPIENT ACCOUNT NUMBER OR I.D. NO.
6. BUDGET PERIOD
(Month, Day, Year)
7. Mark "X" in Appropriate Box New Budget Revised Budget. Enter Grant Number in Box 2 above Date of Budget Revision: (%) (%) Total
Beginning Date: Ending Date: 8. FEDERAL RATE SHARING (%) 9. 10. PROGRAM ACRONYM CFDA NUMBER a. Personnel b. Fringe Benefits c. Travel d. Equipment Object Class e. Supplies f. Contractual g. Construction h. Other i. Total Direct Charges (10a to 10h) j. Indirect Charges k. Total (Sum of 10i & 10j) l. Federal Share Non-Federal Resources: m. Applicant Source n. State o. Local p. Other Sources q. Total (Sum of 10l to 10p) Income Indirect Cost Rate: % 12. Name and Title (Type or print) Total Amount of Indirect Cost: r. Program Income s. Detail on Indirect Cost Type of Rate (mark "X" in one box) Provisional-Final Predetermined (%) (%)
Fixed with Carry-Forward Base:
11. Signature of Authorizing Official
13. Telephone Number (Area code, Number and Extension)
Date Report Submitted
FEMA Form 20-20, FEB 01