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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
REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION Expires July 31, 2008
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. a. TEMPERATURE b. RELATIVE HUMIDITY c. DIRECTION AND VELOCITY OF WINDS
EXISTENCE OF
HIGH
FIRE DANGER d. PREVAILING WEATHER CONDITIONS AND PREDICTIONS FOR NEXT 24 HOURS
CONDITIONS
8. NUMBER OF WILD FIRES
a. CONTROLLED ACRES BURNED b. UNCONTROLLED ACRES BURNED
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: 10. STATE & LOCAL
NATIONAL FIRE DANGER RATING SYSTEM BURN BANS: YES NO
OTHER (KBDI, SPI, HAINES, PALMER, ETC.) 11. NATIONAL
WATCHES: YES NO WARNINGS 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? b. PERSONS EVACUATED:
# YES NO #
20. NAME AND LOCATION OF COMMUNITY THREATENED ADDITIONAL INFORMATION
CITY TOWN
SUBDIVISION
21. CASUALTIES: 22. THREAT TO PRIVATE PROPERTY: (Dwellings)
1. CIVILIAN LOSS OF LIFE 1. NUMBER OF HOMES
2. CIVILIANS INJURED
3. FIRE FIGHTERS LOSS OF LIFE a. % OF PRIMARY b. % OF SECONDARY
4. FIRE FIGHTERS INJURED
23. THREAT TO FACILITIES (Include number when applicable)
AMOUNT TYPE AMOUNT TYPE
BUILDINGS RECREATION
ROADS & BRIDGES EQUIPMENT
INFRASTRUCTURE BUSINESS
UTILITIES OTHER
ADDITIONAL INFORMATION
24. THREAT TO RESOURCES
WATERSHED WILDLIFE (Type threatened, fur-bearing animals, big game, etc.)
IRRIGATION ENVIRONMENTAL RESOURCES (bio-diverse areas, etc.)
FLOOD CONTROL CULTURAL RESOURCES
FISHING STREAMS & SPAWNING SITES ECONOMIC INJURY
ADDITIONAL INFORMATION
IV. STATE ASSESSMENT
25. EMERGENCY MANAGEMENT ASSESSMENT OF THE SITUATION
SIGNATURE DATE
26. FORESTRY ASSESSMENT OF THE SITUATION
SIGNATURE DATE
FEMA REGIONAL USE ONLY
27. NAME OF PERSON WHO RECEIVED OFFICIAL REQUEST TITLE 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 OMB Approval No. 0348-0043
FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Identifier
1. TYPE OF SUBMISSION: 3. DATE RECEIVED BY STATE State Application Identifier
Application Preapplication
Construction Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier
Non-Construction Non-Construction
5. APPLICANT INFORMATION
Legal Name: Organizational Unit:
Address (give city, county, state, and zip code): 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 H. Independent School Dist.
8. TYPE OF APPLICATION: B. County I. State Controlled Institution of Higher Learning
New Continuation Revision C. Municipal J. Private University
D. Township K. Indian Tribe
If Revision, enter appropriate letter(s) in box(es) E. Interstate L. Individual
F. Intermunicipal M. Profit Organization
A. Increase Award B. Decrease Award C. Increase Duration G. Special District N. Other (Specify)
D. Decrease Duration Other (specify):
9. NAME OF FEDERAL AGENCY:
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 $ ORDER 12372 PROCESS?
b. Applicant $ a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE
TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR
c. State $ REVIEW ON:
d. Local $ 0 DATE:
e. Other $ 0 b. NO. PROGRAM IS NOT COVERED BY E.O. 12372
OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR
f. Program Income $ 0 REVIEW
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
g. TOTAL $ .00 Yes 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 Standard Form 424 (REV. 4-92)
Authorized for Local Reproduction Prescribed by OMB Circular A-102
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. NO. 3067-0290
REQUEST FOR FIRE MANAGEMENT ASSISTANCE SUBGRANT Expires July 31, 2008
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 90-133 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) 2. DATE SUBMITTED
Example - Washington
3. COUNTY (location of firefighting activities. If located in multiple counties, please indicate)
Example - Elma
APPLICANT PHYSICAL LOCATION
FEMA
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 Alternate Contact
1. NAME 1. NAME
2. TITLE 2. TITLE
3. BUSINESS PHONE 3. BUSINESS PHONE
4. FAX NUMBER 4. FAX NUMBER
5. HOME PHONE 5. HOME PHONE
6. CELL PHONE 6. CELL PHONE
7. E-MAIL ADDRESS 7. E-MAIL ADDRESS
8. PAGER & PIN NUMBER 8. PAGER & PIN NUMBER
Title 44 CFR Part 204.41 defines Fire Management Assistance eligibility criteria as: (a) The following entities are eligible to apply through a State grantee
for a subgrant under an approved fire management assistance grant: 1) State agencies; 2) Local governments; and 3) Indian Tribal Governments. (b)
Entities that are not eligible to apply for a subgrant as identified in (a), such as privately owned entities and volunteer firefighting organizations, may be
reimbursed through a contract or compact with an eligible applicant for eligible cost associated with the fire or fire complex. (c) Eligibility is contingent
upon the finding that the applicant’s resources were requested by the Incident Commander or comparable State official. (d) The activities performed must
be the legal responsibility of the applying entity, required as a result of the fire or fire complex for which a fire management assistance declaration was
approved, and located within the declared area.
FEMA Form 90-133, NOV 02
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0151
PROJECT WORKSHEET 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 PROJECT NO. PA ID NO. DATE CATEGORY
FEMA -XXXX -DR - XX 000-00000-00 H
DAMAGED FACILITY WORK COMPLETE AS OF
________ : ________ %
APPLICANT COUNTY
Example - Washington Example - Elma
LOCATION LATITUDE LONGITUDE
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? Yes No
Special Considerations included? Yes No Hazard Mitigation proposal included? Yes No
Is there insurance coverage on this facility? Yes No
PROJECT COST
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 $0.00
PREPARED BY TITLE SIGNATURE
APPLICANT REP. TITLE SIGNATURE
FEMA Form 90-91, OCT 02 REPLACES ALL PREVIOUS EDITIONS.
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 O.M.B. No. 3067-0151
Expires July 31, 2008
PROJECT WORKSHEET - Maps and Sketches Sheet
DISASTER PROJECT NO. PA ID NO. DATE CATEGORY
FEMA ___ - DR - ______ H
APPLICANT COUNTY
Example - Washington
FEMA Form 90-91C, OCT 02
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0151
SPECIAL CONSIDERATION QUESTION Expires October 31, 2008
APPLICANT'S NAME DATE
PROJECT NAME LOCATION
Form must be filled out - for each project.
1. 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 O.M.B. No 3067-0151
PAGE ____ OF ____
FORCE ACCOUNT LABOR SUMMARY RECORD Expires October 31, 2008
APPLICANT PA ID NO. PROJECT NO. DISASTER
Example - Washington 000-00000-00
LOCATION/SITE CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma H TO
DESCRIPTION OF WORK PERFORMED
Dates and Hours Worked Each Week Costs
TOTAL
TOTAL HOURLY BENEFIT TOTAL
DATE HOURLY
HOURS RATE RATE/HR COSTS
RATE
NAME
0.00 $0.00 $0.00
REG.
JOB TITLE
0.00 $0.00 $0.00
O.T.
NAME
0.00 $0.00 $0.00
REG.
JOB TITLE
0.00 $0.00 $0.00
O.T.
NAME
0.00 $0.00 $0.00
REG.
JOB TITLE
0.00 $0.00 $0.00
O.T.
NAME
0.00 $0.00 $0.00
REG.
JOB TITLE
0.00 $0.00 $0.00
O.T.
NAME
0.00 $0.00 $0.00
REG.
JOB TITLE
0.00 $0.00 $0.00
O.T.
NAME
0.00 $0.00 $0.00
REG.
JOB TITLE
0.00 $0.00 $0.00
O.T.
TOTAL COST FOR FORCE ACCOUNT LABOR REGULAR TIME $0.00
TOTAL COST FOR FORCE ACCOUNT LABOR OVERTIME $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 0928364a-7834-442b-88bb-c7f6d52d331e.xls, 8
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0151
Page ____ OF ______
MATERIAL SUMMARY SHEET Expires October 31, 2008
APPLICANT PA ID NO. PROJECT NO. DISASTER
Example - Washington
LOCATION/SITE CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma TO
DESCRIPTION OF WORK PERFORMED
INFO FROM
TOTAL DATE DATE
VENDOR DESCRIPTION QUAN. UNIT PRICE (CHECK ONE)
PRICE PURCHASED USED
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 0928364a-7834-442b-88bb-c7f6d52d331e.xls, 10
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0151
PAGE ____ OF _____
RENTED EQUIPMENT SUMMARY RECORD Expires October 31, 2008
APPLICANT PA ID NO. PROJECT NO. DISASTER
Example - Washington 000-00000-00
LOCATION/SITE CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma H TO
DESCRIPTION OF WORK PERFORMED
TYPE OF EQUIPMENT RATE PER HOUR
DATES AND
TOTAL INVOICE DATE AND
Indicate size, Capacity, Horsepower, HOURS W/OUT VENDOR CHECK NO.
W/OPR COST NO. AMOUNT PAID
Make and Models as Appropriate USED OPR
$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 0928364a-7834-442b-88bb-c7f6d52d331e.xls, 12
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0151
PAGE ____ OF _____
CONTRACT WORK SUMMARY RECORD Expires October 31, 2008
APPLICANT PA ID NO. PROJECT NO. DISASTER
Example - Washington
LOCATION/SITE CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma H TO
DESCRIPTION OF WORK PERFORMED
BILLING/INVOICE
DATES WORKED CONTRACTOR AMOUNT COMMENTS - SCOPE
NUMBER
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 0928364a-7834-442b-88bb-c7f6d52d331e.xls, 14
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0151
FORCE ACCOUNT EQUIPMENT SUMMARY RECORD PAGE ___ OF ______ Expires October 31, 2008
APPLICANT PA ID NO. PROJECT NO. DISASTER
Example - Washington
LOCATION/SITE CATEGORY PERIOD COVERING
Example - 12 miles Northeast of Elma H TO
DESCRIPTION OF WORK PERFORMED
Type of Equipment Dates and Hours Used Each Day Costs
INDICATE SIZE, CAPACITY, EQUIPMENT OPERATOR'S
TOTAL EQUIPMENT TOTAL
HORSEPOWER, MAKE AND CODE NAME DATE
HOURS RATE COST
MODEL AS APPROPRIATE NUMBER
Hours
0.0 $0.00
Hours
0.0 $0.00
Hours
0.0 $0.00
Hours
0.0 $0.00
Hours
0.0 $0.00
Hours
0.0 $0.00
Hours
0.0 $0.00
GRAND TOTALS 0.0 $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 90-127, 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 0928364a-7834-442b-88bb-c7f6d52d331e.xls, 16
FEDERAL EMERGENCY MANAGEMENT AGENCY
O.M.B. No. 3067-0151
APPLICANT'S BENEFITS CALCULATION PAGE ____ OF ____ Expires October 31, 2008
WORKSHEET
APPLICANT PA ID NO.
Example - Washington
DISASTER PROJECT NO.
FRINGE BENEFITS (by %) REGULAR TIME OVERTIME
HOLIDAYS
3.8%
VACATION LEAVE
5.8%
SICK LEAVE
4.6%
SOCIAL SECURITY
7.7% 7.7%
MEDICARE
UNEMPLOYMENT
1.5% 1.5%
WORKER'S COMP.
2.0% 2.0%
RETIREMENT
5.5% 5.5%
HEALTH BENEFITS
23.3%
LIFE INS. BENEFITS
1.2%
OTHER
TOTAL in % of annual salary 55.3% 16.6%
COMMENTS
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 ) # 2,080
Pay / Hour $ 20.00
Basic Pay Annualized $ 41,600.00
See note 1
Regular Time % Overtime %
Vacation - days/year # 15 days 120.00 5.8 *
Holidays - days/year # 10 days 80.00 3.8 *
Sick - days/year # 12 days 96.00 4.6 *
Retirement (% of annual salary) ) 5.45 5.45 5.5 5.45 5.5
Social Security - fixed rate % 7.65 7.65 7.7 7.65 7.7
Unemployment % 1.50 1.50 1.5 1.50 1.5
Workman’s Comp % 2.00 2.00 2.0 2.00 2.0
Health Insurance $ 800.00 / mo / employee 23.08 23.1 *
Life Insurance $ 40.00 / mo / employee 1.15 1.2 *
Dental $ 5.00 / mo / employee 0.14 0.1 *
Vision $ 3.00 / mo / employee 0.09 0.1 *
*
% *
Total Percent = 55.3 16.6
Transfer to Data Sheet for Employee
Starting at row F35
Typical ranges 20-60 % 3-20 %
I certify that the information above was transcribed from payroll records or other
documents which are available for audit.
Certified by: ________________________________________
Title: ______________________________________________
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 0928364a-7834-442b-88bb-c7f6d52d331e.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
employee by 2080 (80 hours (2 weeks)/2080 = 3.85%).
4) Fringe benefit percentage for paid holidays: Divide the number of paid holiday hours by 2080 (64 hours (8
holidays)/2080 = 3.07%).
5) Retirement pay: Because this measure varies widely, use only the percentage of salary matched by the employer.
6) Social Security and Unemployment Insurance: Both are standard percentages of salary.
7) Insurance: This benefit varies by employee. Divide the amount paid by the city or county by the basic pay rate
determined in Step 2.
8) 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 7.65% (or slightly less)
Retirement--Regular 17.00% (or less)
Retirement--Special Risk 25.00% (or slightly more)
Health Insurance 12.00% (or less)
Life & Disability Insurance 1.00% (or less)
Worker's Compensation 3.00% (or less)
Unemployment Insurance 0.25% (or less)
Leave Fringe Benefits
Accrued Annual Leave 7.00% (or less)
Sick Leave 4.00% (or less)
Administrative Leave 0.50% (or less)
Holiday Leave 4.00% (or less)
Compensatory Leave 2.00% (or less)
Rates outside of these ranges are possible, but should be justified during the validation process.
updated 5/6/05 0928364a-7834-442b-88bb-c7f6d52d331e.xls, 19
FEDERAL EMERGENCY MANAGEMENT AGENCY See Reverse for Instructions and OMB NO. 3067-0206
FINANCIAL STATUS REPORT Paperwork Burden Disclosure Notice Page ___ of ___ pages Expires February 28, 2007
1. FEDERAL AGENCY AND ORGANIZATIONAL 2. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED ASSIGNED
4. EMPLOYER I.D. NO. 5. RECIPIENT ACCT. NO. OR I.D. 6. FINAL REPORT 7. BASE 8. Funding/Grant Period 9. Period Covered This Report
YES CASH From: From:
NO ACCRUAL To: To:
STATUS OF REPORT
10. (a) (b) (c) (d) (e)
PROGRAM ACRONYM TOTAL
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)
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) Provisional-Final Predetermined Fixed with carry forward
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.
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 SIGNATURE OF AUTHORIZED REPRESENTATIVE TELEPHONE NO. (Include area code, and extension) DATE
FEMA Form 20-10, MAR 01
FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-02006
SUMMARY SHEET FOR ASSURANCES AND CERTIFICATIONS Expires September 30, 1998
DATE: APPLICANT LEGAL NAME:
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 FEMA Form 20-16A, Assurances-Nonconstruction Programs
Part II FEMA Form 20-16B, Assurances-Construction Programs
Part III FEMA Form 20-16C, Certifications Regarding Lobbying;
Debarment, Suspension, and Other Responsibility
Matters; and Drug-Free Workplace Requirements
Part IV SF LLL, Disclosure of Lobbying Activities (If applicable)
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, alcohol abuse or alcoholism; (g) Sections 523 and 527 of
and the institutional, managerial and financial capability the Public Health Service Act of 1912 (42 U.S.C. 290-dd-3
(including funds sufficient to pay the non-Federal share of and 290-ee-3), as amended, relating to confidentiality of
project costs) to ensure proper planning, management and alcohol and drug abuse patient records; (h) Title VIII of the
completion of the project described in this application. Civil Rights Acts of 1968 (42 U.S.C. Section 3601 et seq.),
as amended, relating to nondiscrimination in the sale,
2. Will give the awarding agency, the Comptroller rental or financing of housing; (i) any other
General of the United States, and if appropriate, the State, nondiscrimination provisions in the specific statute(s)
through any authorized representative, access to and the under which application for Federal assistance is being
right to examine all records, books, papers, or documents made; and (j) the requirements of any other
related to the award; and will establish a proper accounting nondiscrimination statute(s) which may apply to the
system in accordance with generally accepted accounting application.
standards or agency directives.
7. Will comply, or has already complied, with the
3. Will establish safeguards to prohibit employees from requirements of Title II and III of the Uniform
using their positions for a purpose that constitutes or Relocation Assistance and Real Property Acquisition
presents the appearance of personal gain. Policies Act of 1970 (P.L. 91-646) which provide for fair
and equitable treatment of persons displaced or whose
4. Will initiate and complete the work within the property is acquired as a result of Federal or Federally
applicable time frame after receipt of approval of the assisted programs. These requirements apply to all
awarding agency. interest in real property acquired for project purposes
regardless of Federal participation in purchases.
5. Will comply with the Intergovernmental Personnel
Act of 1970 (42 U.S.C. Section 4728-4763) relating to 8. Will comply with provisions of the Hatch Act (5
prescribed standards for merit systems for programs U.S.C. Sections 1501-1508 and 7324-7328) which limit
funded under one of the nineteen statutes or regulations the political activities of employees whose principal
specified in Appendix A of OPM's Standards for a Merit employment activities are funded in whole or in part
System of Personnel Administration) 5 C.F.R. 900, with Federal funds.
Subpart F).
9. Will comply, as applicable, with the provisions of
6. Will comply with all Federal statutes relating to the Davis-Bacon Act (40 U.S.C. Sections 276a to 276a-
nondiscrimination. These include but are not limited to: 7), the Copeland Act (40 U.S.C. Section 276c and 18
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) U.S.C. Sections 874), and the Contract Work Hours
which prohibits discrimination on the basis of race, color and Safety Standards Act (40 U.S.C. Sections 327-333),
or national origin; (b) Title IX of the Education Amendments regarding labor standards for federally assisted
of 1972, as amended (20 U.S.C. Sections 1681-1683, and construction subagreements.
1685-1686), which prohibits discrimination on the basis of
sex; (c) Section 504 of the Rehabilitation Act of 1973, as 10. Will comply, if applicable, with flood insurance
amended (29 U.S.C. Section 794), which prohibits purchase requirements of Section 102(a) of the Flood
discrimination on the basis of handicaps; (d) the Age Disaster Protection Act of 1973 (P.L. 93-234) which
Discrimination Act of 1975, as amended (42 U.S.C. requires recipients in a special flood hazard area to
Sections 6101-6107), which prohibits discrimination on the participate in the program and to purchase flood
basis of age; (e) the Drug Abuse Office and Treatment Act insurance if the total cost of insurable construction and
of 1972 (P.L. 92-255), as amended, relating to acquisition is $10,000 or more.
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
11. Will comply with environmental standards which may 14. Will comply with P.L. 93-348 regarding the
be prescribed pursuant to the following: (a) institution protection of human subjects involved in research,
of environmental quality control measures under the development, and related activities supported by this
National Environmental Policy Act of 1969 (P.L. 91-190) award of assistance.
and Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands 15. Will comply with the Laboratory Animal Welfare Act
pursuant to EO 11990; (d) evaluation of flood hazards in of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131 et seq.)
floodplains in accordance with EO 11988; (e) assurance of pertaining to the care, handling, and treatment of warm
project consistency with the approved State management blooded animals held for research, teaching, or other
program developed under the Coastal Zone Management activities supported by this award of assistance.
Act of 1972 (16 U.S.C. Section 1451 et seq.); (f) conformity
of Federal actions to State (Clean Air) Implementation 16. Will comply with the Lead-Based Paint Poisoning
Plans under Section 176(c) of the Clean Air Act of 1955, Prevention Act (42 U.S.C. Section 4801 et seq.) which
as amended (42 U.S.C. Section 7401 et seq.); (g) protection prohibits the use of lead based paint in construction or
of underground sources of drinking water under the Safe rehabilitation of residence structures.
Drinking Water Act of 1974, as amended, (P.L. 93-523);
and (h) protection of endangered species under the 17. Will cause to be performed the required financial
Endangered Species Act of 1973, as amended, and compliance audits in accordance with the Single
(P.L. 93-205). Audit Act of 1984.
12. Will comply with the Wild and Scenic Rivers Act of 18. Will comply with all applicable requirements of all
1968 (16 U.S.C. Section 1271 et seq.) related to other Federal laws, executive orders, regulations and
protecting components or potential components of policies governing this program.
the national wild and scenic rivers system.
19. It will comply with the minimum wage and maximum
13. Will assist the awarding agency in assuring hours provisions of the Federal Fair Labor Standards
compliance with Section 106 of the National Historic Act (29 U.S.C. 201), as they apply to employees of
Preservation Act of 1966, as amended (16 U.S.C. 470), institutions of higher education, hospitals, and other
EO 11593 (identification and protection of historic non-profit organizations.
properties), and the Archaeological and Historic
Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
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, 9. Will comply with the Lead-Based Paint Poisoning
and the institutional, managerial and financial capability Prevention Act (42 U.S.C. Sections 4801 et seq.) which
(including funds sufficient to pay the non-Federal share of prohibits the use of lead based paint in construction or
project costs) to ensure proper planning, management and rehabilitation of residence structures.
completion of the project described in this application.
10. Will comply with all Federal statutes relating to
2. Will give the awarding agency, the Comptroller non-discrimination. These include but are not limited to:
General of the United States, and if appropriate, the State, (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
through any authorized representative, access to and the which prohibits discrimination on the basis of race, color
right to examine all records, books, papers, or documents or national origin; (b) Title IX of the Education Amendments
related to the assistance; and will establish a proper of 1972, as amended (20 U.S.C. Sections 1681-1683, and
accounting system in accordance with generally accepted 1685-1686), which prohibits discrimination on the basis of
accounting standards or agency directives. sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. Section 794), which prohibits
3. Will not dispose of, modify the use of, or change the discrimination on the basis of handicaps; (d) the Age
terms of the real property title, or other interest in the site Discrimination Act of 1975, as amended (42 U.S.C.
and facilities without permission and instructions from Sections 6101-6107), which prohibits discrimination on the
the awarding agency. Will record the Federal interest in basis of age; (e) the Drug Abuse Office and Treatment Act
the title of real property in accordance with awarding of 1972 (P.L. 92-255), as amended, relating to
agency directives and will include a covenant in the non-discrimination on the basis of drug abuse; (f) the
title of real property acquired in whole or in part with Comprehensive Alcohol Abuse and Alcoholism Prevention,
Federal assistance funds to assure nondiscrimination Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as
during the useful life of the project. amended, relating to non-discrimination on the basis of
alcohol abuse or alcoholism; (g) Sections 523 and 527 of
4. Will comply with the requirements of the assistance the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3
awarding agency with regard to the drafting, review and and 290 ee-3), as amended, relating to confidentiality of
approval of construction plans and specifications. alcohol and drug abuse patient records; (h) Title VIII of the
Civil Rights Acts of 1968 (42 U.S.C. Section 3601 et seq.),
5. Will provide and maintain competent and adequate as amended, relating to non-discrimination in the sale, rental
engineering supervision at the construction site to ensure or financing of housing; (i) any other non-discrimination
that the complete work conforms with the approved plans provision in the specific statute(s) under which application
and specifications and will furnish progress reports and for Federal assistance is being made; and (j) the
such other information as may be required by the requirements of any other non-discrimination statute(s)
assistance awarding agency or state. which may apply to the application.
6. Will initiate and complete the work within the applicable 11. Will comply, or has already complied, with the
time frame after receipt of approval of the awarding agency. requirements of Title II and III of the Uniform
Relocation Assistance and Real Property Acquisition
7. Will establish safeguards to prohibit employees from Policies Act of 1970 (P.L. 91-646) which provide for fair
using their positions for a purpose that constitutes or and equitable treatment of persons displaced or whose
presents the appearance of personal or organizational property is acquired as a result of Federal or Federally
conflict of interest, or personal gain. assisted programs. These requirements apply to all
interest in real property acquired for project purposes
8. Will comply with the Intergovernmental Personnel Act regardless of Federal participation in purchase.
of 1970 (42 U.S.C. Sections 4728-4763) relating to prescribed
standards for merit systems for programs funded under one 12. Will comply with provisions of the Hatch Act (5 U.S.C.
of the nineteen statutes or regulations specified in Sections 1501-1508 and 7324-7328) which limit the
Appendix A of OPM's Standards for a Merit System of political activities of employees whose principal employment
Personnel Administration (5 C.F.R. 900, Subpart F). activities are funded in whole or in part with Federal funds.
FEMA Form 20-16B, JUN 94
13. Will comply, as applicable, with the provisions of the 20. It will comply with the minimum wage and maximum
Davis-Bacon Act (40 U.S.C. Sections 276a to 276a-7), hours provisions of the Federal Fair Labor Standards
the Copeland Act (40 U.S.C. Section 276c and 18 U.S.C. Act (29 U.S.C. 201), as they apply to employees of
Section 874), the Contract Work Hours and Safety institutions of higher education, hospitals, and other
Standards Act (40 U.S.C. Sections 327-333) regarding non-profit organizations.
labor standards for federally assisted construction
subagreements. 21. It will obtain approval by the appropriate Federal
agency of the final working drawings and specifications
14. Will comply with the flood insurance purchase before the project is advertised or placed on the market
requirements of Section 102(a) of the Flood Disaster for bidding; that it will construct the project, or cause it to
Protection Act of 1973 (P.L. 93-234) which requires be constructed, to final completion in accordance with the
recipients in a special flood hazard area to participate in application and approved plans and specifications; that it
the program and to purchase flood insurance if the total will submit to the appropriate Federal agency for prior
cost of insurable construction and acquisition is $10,000 approval changes that alter the cost of the project, use of
or more. space, or functional layout, that it will not enter into a
construction contract(s) for the project or undertake other
15. Will comply with environmental standards which may activities until the conditions of the construction grant
be prescribed pursuant to the following: (a) institution program(s) have been met.
of environmental quality control measures under the
National Environmental Policy Act of 1969 (P.L. 91-190) 22. It will operate and maintain the facility in accordance
and Executive Order (EO) 11514; (b) notification of violating with the minimum standards as may be required or
facilities pursuant to EO 11738; (c) protection of wetlands prescribed by the applicable Federal, State, and local
pursuant to EO 11990; (d) evaluation of flood hazards in agencies for the maintenance and operation of such
floodplains in accordance with EO 11988; (e) assurance of facilities.
project consistency with the approved State management
program developed under the Coastal Zone Management 23. It will require the facility to be designed to comply
Act of 1972 (16 U.S.C. Section 1451 et seq.); (f) conformity with the "American Standard Specifications for Making
of Federal actions to State (Clean Air) Implementation Buildings and Facilities Accessible to, and Usable by,
Plans under Section 176(c) of the Clean Air Act of 1955, the Physically Handicapped," Number A117. - 1961, as
as amended (42 U.S.C. Section 7401 et seq.); (g) protection modified (41 CFR 101-17.703). The applicant will be
of underground sources of drinking water under the Safe responsible for conducting inspections to ensure
Drinking Water Act of 1974, as amended, (P.L. 93-523); compliance with these specifications by the contractor.
and (h) protection of endangered species under the
Endangered Species Act of 1973, as amended, (P.L. 93-205). 24. If any real property or structure thereon is provided
or improved with the aid of Federal financial assistance
16. Will comply with the Wild and Scenic Rivers Act of extended to the applicant, this assurance shall obligate
1968 (16 U.S.C. Section 1271 et seq.) related to the applicant, or in the case of any transfer of such
protecting components or potential components of the property, any transfer, for the period during which the
national wild and scenic rivers system. real property or structure is used for a purpose for which
the Federal financial assistance is extended or for
17. Will assist the awarding agency in assuring another purpose involving the provision of similar
compliance with Section 106 of the National Historic services or benefits.
Preservation Act of 1966, as amended (16 U.S.C. 470),
EO 11593 (identification and preservation of historic 25. In making subgrants with nonprofit institutions
properties), and the Archaeological and Historic under this Comprehensive Cooperative Agreement, it
Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.). agrees that such grants will be subject to OMB Circular
A-122, "Cost Principles for Non-profit Organizations"
18. Will cause to be performed the required financial included in Vol. 49, Federal Register, pages 18260
and compliance audits in accordance with the Single Audit through 18277 (April 27, 1984).
Act of 1984.
19. Will comply with all applicable requirements of all
other Federal laws, Executive Orders, regulations and
policies governing this program.
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 (b) Have not within a three-year period preceding this application been
convicted of ar had a civilian judgment rendered against them for
A. As required by section 1352, Title 31 of the U.S. Code, and commission of fraud or a criminal offense in connection with
implemented at 44 CFR Part 18, for persons entering into a grant obtaining, attempting to obtain, or perform a public (Federal, State,
or cooperative agreement over $100,000, as defined at 44 CFR or local) transaction or contract under a public transaction; violation
Part 18, the applicant certifies that: of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records,
(a) No Federal appropriated funds have been paid or will be paid, making false statements, or receiving stolen property;
by or on behalf of the undersigned, to any person for influencing or
attempting to influence an officer or employee of any agency, a (c) Are not presently indicted for or otherwise criminally or civilly
Member of Congress, an officer or employee of congress, or an charged by a governmental entity (Federal, State, or local) with
employee of a Member of Congress in connection with the making commission of any of the offenses enumerated in paragraph (1)(b)
of any Federal grant, the entering into of any cooperative agreement, of this certification; and
and the extension, continuation, renewal, amendment, or modification
of any Federal grant or cooperative agreement; (d) Have not within a three-year period preceding this application
had one or more public t ransactions (Federal, State, or local)
(b) If any other funds than Federal appropriated funds have been terminated for cause or default; and
paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a Member of B. Where the applicant is unable to certify to any of the statements
Congress, an officer or an employee of Congress, or employee in this certification, he or shall shall attached an explanation to this
of a member of Congress in connection with this Federal grant or application.
cooperative agreement, the undersigned shall complete and submit
Standard Form LLL, "Disclosure of Lobbying Activities," in 3. DRUG-FREE WORKPLACE
accordance with its instructions; (GRANTEES OTHER THAN INDIVIDUALS)
(c) The undersigned shall require that the language of this certification As required by the Drug-Free Workplace Act of 1988, and
be included in the award documents for all subawards at all tiers implemented at 44 CFR Part 17, Subpart F, for grantees, as defined
(including subgrants, contracts under grants and cooperative at 44 CFR Part 17, Sections 17.615 and 17.620:
agreements, and subcontract(s) and that all subrecipients shall
certify and disclose accordingly. A. The applicant certifies that it will continue to privide a drug-
free workplace by:
Standard Form LLL, "Disclosure of Lobbying Activities" attached.
(This form must be attached to certification if nonappropriated funds (a) Publishing a statement notifying employees that the unlawful
are to be used to influence activities.) manufacture, distribution, dispensing, possession, or use of a
controlled substance is prohibited in the grantee's workplace and
2. DEBARMENT, SUSPENSION, AND OTHER specifying the actions tht will be taken against employees for
RESPONSIBILITY MATTERS violation of such prohibition;
(DIRECT RECIPIENT)
(b) Establishing an on-going drug free awareness program to
As required by Executive Order 12549, Debarment and Suspension, inform empoyees about:
and implemented at 44 CFR Part 67, for prospective participants in
primary covered transactions, as defined at 44 CFR Part 17, (1) The dangers of drug abuse in the workplace;
Section 17.510-A. The applicant certifies that it and its principals: (2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and
(a) Are not presently debarred, suspended, proposed for debarment, employee assistance programs; and
declared ineligible, sentenced to a denial of Federal benefits by a State (4) the penalties that may be imposed upon employees for
or Federal court, or voluntarily excluded from covered transactions by drug abuse violations occurring in the workplace;
any Federal department or agency;
FEMA Form 20-16C, JUN 94
(c) Making it a requirement that each employee to be engaged in (2) Requiring such employee to participate satisfactorily in a
the performance of the grant to be given a copy of the statement drug abuse assistance or rehabilitation program approved for
required by paragraph (a); such purposes by a Federal, State, or local health, law enforcement,
or other appropriate agency.
(d) Notifying the employee in the statement required by
paragraph (a) that, as a condition of employment under the grant, (g) Making a good faith effort to continue to maintain a drug free
the employee will: workplace through implementation of paragraphs (a), (b), (c), (d), (e),
and (f).
(1) Abide by the terms of the statement; and
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 the performance of work done in connection with the specific grant:
violation of a criminal drug statute occurring in the workplace no later
than five calendar days after such conviction. Place of Performance (Street address, City, County, State, Zip code)
(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.
Check if there are workplaces on file that are not identified here.
(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: 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
(1) Taking appropriate personnel action against such an employee, of which should be included with each application for FEMA funding.
up to and including termination, consistent with the requirements States and State agencies may elect to use a Statewide certification.
of the Rehabilitation Act of 1973, as amended; or
FEMA Form 20-16C (BACK)
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046
(See reverse for public burden disclosure)
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
a. contract a. bid/offer/application a. initial filing
b. grant b. initial award b. material change
c. cooperative agreement c. post-award For Material Change Only:
d. loan year quarter
e. loan guarantee date of last report
f. loan insurance
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name
Prime Subawardee and Address of Prime:
Tier , if known:
Congressional District, if known: Congressional District, if known:
6. Federal Department/Agency: 7. Federal Program Name/Description:
CFDA Number, if applicable:
8. Federal Action Number, if known: 9. Award Amount, if known:
$
10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if
(if individual, last name, first name, MI): 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 Signature:
representation of fact upon which reliance was placed by the tier
above when this transaction was made or entered into. This Print Name:
disclosure is required pursuant to 31 U.S.C. 1352. This information
will be reported to the Congress semi-annually and will be Title:
available for public inspection. Any person who fails to file the
required disclosure shall be subject to a civil penalty of not less Telephone No.: Date:
than $10,000 and not more than $100,000 for each such failure.
Federal Use Only: Authorized for Local Reproduction
Standard Form - LLL
WORKSHEET FOR BUDGET NARRATIVE
NONCONSTRUCTION PROGRAMS OBJECT CLASS CATEGORY: Personnel Page 1 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
12.
(a) (b) (c) (d) (e)
POSITION POSITION DATE
POSITION TITLE NUMBER TYPE HIRE VACANCY
Comments:
Page 1 of 10 pages CHECK POINT
ddress, including zip code)
TOTAL STATE & FEDERAL PERSONNEL 0.00
FROM WORKSHEET
TOTAL STATE & FEDERAL PERSONNEL #REF!
FROM FEMA FORMS 20-20
Enter Grant Number in Box 2 above
DIFFERENCE #REF!
(i) (j) (k)
% OF TOTAL STATE & % OF TOTAL STATE & % OF TOTAL STATE &
(f) (g) (h) SALARY FEDERAL SAL. SALARY FEDERAL SAL. SALARY FEDERAL SAL.
DATE OF SALARY 83.534 83.534
INCREASE WORK YEARS ANNUAL SALARY SLA 100 SLA 50
0.000 0.00 0.00 0.00 0.00
(l) (m) (n) (o) (p)
% OF TOTAL STATE & % OF TOTAL STATE & % OF TOTAL STATE & % OF TOTAL STATE & % OF TOTAL STATE &
SALARY FEDERAL SAL. SALARY FEDERAL SAL. SALARY FEDERAL SAL. SALARY FEDERAL SAL. SALARY FEDERAL SAL.
83.011 83.505 83.550
SARA DPIG NDSP
0.00 0.00 0.00 0.00 0.00
(q) (r) (s) (t) (u)
% OF TOTAL STATE & % OF TOTAL STATE & % OF TOTAL STATE & % OF TOTAL STATE & % OF TOTAL STATE &
SALARY FEDERAL SAL. SALARY FEDERAL SAL. SALARY FEDERAL SAL. SALARY FEDERAL SAL. SALARY FEDERAL SAL.
83.105 83.535 83.536 83.536 83.549
CAP-SSSE MAP FMA PL FMA TA CSEPP O&M
0.00 0.00 0.00 0.00 0.00
(v) (w)
% OF TOTAL STATE & % OF
SALARY FEDERAL SAL. SALARY
83.549
CSEPP PROC 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 OBJECT CLASS CATEGORY: Fringe Benefits Page 2 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
OPTION #1
12. (b) (c)
(a) 83.534 83.534
SLA 100 SLA 50
TOTAL SALARY 0.00 0.00 0.00 0.00
PERCENTAGE APPLIED
FRINGE BENEFITS
OPTION #2
13.
(a) (b) (c) (d)
83.534 83.534
DESCRIPTION AMOUNT SLA 100 SLA 50
0.00 0.00 0.00 0.00 0.00
TOTAL 0.00 0.00 0.00 0.00
Comments:
Page 2 of 10 pages CHECK POINT
ddress, including zip code)
TOTAL FRINGE BENEFITS 0.00
FROM WORKSHEET
TOTAL FRINGE BENEFITS #REF!
FROM FEMA FORMS 20-20
Enter Grant Number in Box 2 above
DIFFERENCE #REF!
(f) (g) (h) (i) (j) (k) (l)
83.011 83.505 83.550 83.105 83.535 83.536
SARA DPIG NDSP CAP-SSSE MAP FMA PL
0.00 0.00 0.00 0.00 0.00 0.00 0.00
(g) (h) (i) (j) (k) (l) (m)
83.011 83.505 83.550 83.105 83.535 83.536
SARA DPIG NDSP CAP-SSSE MAP 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 83.549 83.549
FMA TA CSEPP O&M CSEPP PROC Non-Federal
0.00 0.00 0.00 0.00
(n) (o) (p) (q)
83.536 83.549 83.549
FMA TA CSEPP O&M CSEPP PROC Non-Federal
0.00
0.00
0.00
0.00
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: 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 OBJECT CLASS CATEGORY: Travel Page 3 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
12. TOTAL MILEAGE
(c X d X e) =
(a) (b) (c) (d) (e) (f)
TOTAL NUMBER NUMBER OF NUMBER OF MILEAGE
DESCRIPTION OF TRAVEL OF TRAVELERS TRAVELERS 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
ddress, including zip code)
TOTAL TRAVEL 0.00
FROM WORKSHEET
TOTAL TRAVEL #REF!
FROM FEMA FORMS 20-20
Enter Grant Number in Box 2 above
DIFFERENCE #REF!
TAXI / LIMO AIRFARE PER D
(g X h) = (j X k) =
(g) (h) (i) (j) (k) (l) (m)
NUMBER OF TAXI LIMO NUMBER OF AIRFARE PER NUMBER OF
TRAVELERS PER TRAVELER TOTAL TAXI LIMO TRAVELERS TRAVELER TOTAL AIRFARE TRAVELERS
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
PER DIEM MISCELLANEOUS TOTAL
(m X n X o) = (q X r) = (f + i + l + p + s) =
(n) (o) (p) (q) (r) (s) (t) (u)
NUMBER OF DAYS NUMBER OF MISC COSTS TOTAL
PER DIEM PER TRAVELER TOTAL PER DIEM TRAVELERS PER TRAVELER MISC COSTS TOTAL COST PRIORITY
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
(v) (w) (x) (y) (z) (aa) (ab) (ac) (ad)
TRAVEL TRAVEL TRAVEL TRAVEL TRAVEL TRAVEL TRAVEL TRAVEL TRAVEL
COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS
83.534 83.534 83.011 83.505 83.550 83.105
SLA 100 SLA 50 SARA DPIG NDSP 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 TRAVEL TRAVEL TRAVEL TRAVEL (v thru ai) = (t - aj) =
COSTS COSTS COSTS COSTS COSTS (aj) (ak)
83.535 83.536 83.536 83.549 83.549
MAP FMA PL FMA TA CSEPP O&M CSEPP PROC TOTAL 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 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 OBJECT CLASS CATEGORY: Equipment Page 4 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
12. (f)
(b X c) = EQUIPMENT
(a) (b) (c) (d) (e) COSTS
83.534
DESCRIPTION OF EQUIPMENT UNIT COST QUANTITY TOTAL COST PRIORITY SLA 100
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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 4 of 10 pages CHECK POINT
ddress, including zip code)
TOTAL EQUIPMENT COSTS 0.00
FROM WORKSHEET
TOTAL EQUIPMENT COSTS #REF!
FROM FEMA FORMS 20-20
Enter Grant Number in Box 2 above
DIFFERENCE #REF!
(g) (h) (i) (j) (k) (l) (m)
EQUIPMENT EQUIPMENT EQUIPMENT EQUIPMENT EQUIPMENT EQUIPMENT EQUIPMENT
COSTS COSTS COSTS COSTS COSTS COSTS COSTS
83.534 83.011 83.505 83.550
SLA 50 SARA DPIG NDSP
0.00 0.00 0.00 0.00 0.00 0.00 0.00
(n) (o) (p) (q) (r) (s)
EQUIPMENT EQUIPMENT EQUIPMENT EQUIPMENT EQUIPMENT EQUIPMENT (f thru s) = (d - t) =
COSTS COSTS COSTS COSTS COSTS COSTS (t) (u)
83.105 83.535 83.536 83.536 83.549 83.549
CAP-SSSE MAP FMA PL FMA TA CSEPP O&M CSEPP PROC TOTAL 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 0.00
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 OBJECT CLASS CATEGORY: Supplies Page 5 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
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
ddress, including zip code)
TOTAL SUPPLY COSTS 0.00
FROM WORKSHEET
TOTAL SUPPLY COSTS #REF!
FROM FEMA FORMS 20-20
Enter Grant Number in Box 2 above
DIFFERENCE #REF!
(g) (h) (i) (j) (k) (l)
SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY
(f) COSTS COSTS COSTS COSTS COSTS COSTS
83.534 83.534 83.011
PRIORITY SLA 100 SLA 50 SARA
0.00 0.00 0.00 0.00 0.00 0.00
(m) (n) (o) (p) (q) (r) (s) (t)
SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY SUPPLY
COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS
83.505 83.550 83.105 83.535 83.536 83.536 83.549 83.549
DPIG NDSP CAP-SSSE MAP FMA PL FMA TA CSEPP O&M CSEPP PROC
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
(g thru t) = (e - u) =
(u) (v)
TOTAL 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 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 OBJECT CLASS CATEGORY: Contractual Page 6 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
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
ddress, including zip code)
TOTAL CONTRACTUAL COSTS 0.00
FROM WORKSHEET
TOTAL CONTRACTUAL COSTS #REF!
FROM FEMA FORMS 20-20
Enter Grant Number in Box 2 above
DIFFERENCE #REF!
(g) (h) (i) (j) (k) (l)
CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL
(f) COSTS COSTS COSTS COSTS COSTS COSTS
83.534 83.534 83.011
PRIORITY SLA 100 SLA 50 SARA
0.00 0.00 0.00 0.00 0.00 0.00
(m) (n) (o) (p) (q) (r) (s) (t)
CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL CONTRACTUAL
COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS
83.505 83.550 83.105 83.535 83.536 83.536 83.549 83.549
DPIG NDSP CAP-SSSE MAP FMA PL FMA TA CSEPP O&M CSEPP PROC
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
(g thru t) = (e - u) =
(u) (v)
TOTAL 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 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 OBJECT CLASS CATEGORY: SLA Counties Page 7 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
A. B. C. NUMBER OF PAID PERSONNEL
(1 + 2) =
(State or Local Organization) (1) (2) (3)
TEN NAME OF APPLICANT FULL TIME PART TIME TOTAL
GRAND TOTAL 0 0
Page 7 of 10 pages CHECK POINT
ddress, including zip code)
TOTAL SLA COUNTIES COSTS 0.00
FROM WORKSHEET
TOTAL SLA COUNTIES COSTS 0.00
FROM FEMA FORM 20-20
Enter Grant Number in Box 2 above
DIFFERENCE 0.00
ERSONNEL WORK YEARS D. DIRECTOR E. TOTAL ESTIMATED EXPENS
(1 + 2) = (4 + 5) =
(3) (4) (5) (6) SLA PAID (1) (2)
TOTAL PROFESSIONAL CLERICAL TOTAL PAID OTHER VOLUNTEER PERSONNEL TRAVEL
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 0.00
0 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 OBJECT CLASS CATEGORY: Construction Page 8 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
12. (d) (e)
CONSTRUCTION CONSTRUCTION
(a) (b) (c) COSTS COSTS
83.534 83.534
NARATIVE DESCRIPTION TOTAL COST PRIORITY SLA 100 SLA 50
0.00 0.00 0.00
Comments:
Page 8 of 10 pages CHECK POINT
ddress, including zip code)
TOTAL CONSTRUCTION COSTS 0.00
FROM WORKSHEET
TOTAL CONSTRUCTION COSTS #REF!
FROM FEMA FORMS 20-20
Enter Grant Number in Box 2 above
DIFFERENCE #REF!
(f) (g) (h) (i) (j) (k) (l)
CONSTRUCTION CONSTRUCTION CONSTRUCTION CONSTRUCTION CONSTRUCTION CONSTRUCTION CONSTRUCTION
COSTS COSTS COSTS COSTS COSTS COSTS COSTS
83.011 83.505 83.550 83.105
SARA DPIG NDSP CAP-SSSE
0.00 0.00 0.00 0.00 0.00 0.00 0.00
(m) (n) (o) (p) (q)
CONSTRUCTION CONSTRUCTION CONSTRUCTION CONSTRUCTION CONSTRUCTION (d thru q) = (b - r) =
COSTS COSTS COSTS COSTS COSTS (r) (s)
83.535 83.536 83.536 83.549 83.549
MAP FMA PL FMA TA CSEPP O&M CSEPP PROC TOTAL 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 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 OBJECT CLASS CATEGORY: Other Page 9 of 10 pages
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
12.
(b X c) =
(a) (b) (c) (d) (e) (f)
NARRATIVE DESCRIPTION UNIT COST QUANTITY UNIT DESCRIPTION TOTAL COST PRIORITY
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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:
CHECK POINT
TOTAL OTHER COSTS 0.00
FROM WORKSHEET
TOTAL OTHER COSTS #REF!
FROM FEMA FORMS 20-20
DIFFERENCE #REF!
(g) (h) (i) (j) (k) (l) (m) (n)
OTHER OTHER OTHER OTHER OTHER OTHER OTHER OTHER
COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS
83.534 83.534 83.011 83.505 83.550
SLA 100 SLA 50 SARA DPIG NDSP
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
(o) (p) (q) (r) (s) (t)
OTHER OTHER OTHER OTHER OTHER OTHER (g thru t) = (e - u) =
COSTS COSTS COSTS COSTS COSTS COSTS (u) (v)
83.105 83.535 83.536 83.536 83.549 83.549
CAP-SSSE MAP FMA PL FMA TA CSEPP O&M CSEPP PROC TOTAL 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 0.00
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 OBJECT CLASS CATEGORY: Indirect Costs Page 10 of 10 pages CHECK POINT
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED TOTAL INDIRECT COSTS #REF!
FROM WORKSHEET
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box TOTAL INDIRECT COSTS #REF!
(Month, Day, Year) New Budget FROM FEMA FORMS 20-20
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision: DIFFERENCE #REF!
8. PROGRAM AND CFDA NUMBER: 9. FUNCTION: 10. ACTIVITY: 11. TASK:
OPTION #1
12.
(a) (b) (c) (d) (e) (f) (g) (h) (i) (j)
EFFECTIVE PERIOD OF RATE TOTAL PERSONNEL NEGOTIATED INDIRECT COSTS 83.534 83.534 83.011
AGREEMENT & FRINGE BENEFITS RATE CLAIMED SLA 100 SLA 50 SARA
#REF! #REF! TOTAL PERSONNEL & 0.00 0.00 0.00 0.00 #REF!
FRINGE BENEFITS
NEGOTIATED RATE
INDIRECT COSTS
CLAIMED 0.00 0.00 0.00 0.00 #REF!
OPTION #2
13.
(a) (b) (c) (d) (e) (f) (g) (h)
EFFECTIVE PERIOD OF RATE 83.534 83.534 83.011
AGREEMENT COMMENTS SLA 100 SLA 50 SARA
TOTAL DIRECT CHARGES #REF! 0.00 0.00 0.00 0.00 #REF!
LESS
LESS
LESS
TOTAL #REF! 0.00 0.00 0.00 0.00 #REF!
NEGOTIATED RATE
INDIRECT COSTS CLAIMED #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 83.534 83.534 83.011
AGREEMENT COMMENTS SLA 100 SLA 50 SARA
BASE
NEGOTIATED RATE
INDIRECT COSTS CLAIMED 0.00 0.00 0.00 0.00 0.00 0.00
BASE
NEGOTIATED RATE
INDIRECT COSTS CLAIMED 0.00 0.00 0.00 0.00 0.00 0.00
BASE
NEGOTIATED RATE
INDIRECT COSTS CLAIMED 0.00 0.00 0.00 0.00 0.00 0.00
TOTAL INDIRECT COSTS CLAIMED 0.00 0.00 0.00 0.00 #REF!
TOTAL STATE & FEDERAL INDIRECT COSTS CLAIMED #REF!
(k) (l) (m) (n) (o) (p) (q) (r) (s) (t)
83.505 83.550 83.105 83.535 83.536 83.536 83.549 83.549
DPIG NDSP CAP-SSSE MAP FMA PL FMA TA CSEPP O&M CSEPP PROC Non-Federal
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! 0.00
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! 0.00
(i) (j) (k) (l) (m) (n) (o) (p) (q)
83.505 83.550 83.105 83.535 83.536 83.536 83.549 83.549
DPIG NDSP CAP-SSSE MAP FMA PL FMA TA CSEPP O&M CSEPP PROC
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
(d thru q) = (c - s) =
(i) (j) (k) (l) (m) (n) (o) (p) (q) (r) (s) (t)
83.505 83.550 83.105 83.535 83.536 83.536 83.549 83.549
DPIG NDSP CAP-SSSE MAP FMA PL FMA TA CSEPP O&M CSEPP PROC Non-Federal TOTAL 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 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 OMB No. 3067-0206
BUDGET INFORMATION--NONCONSTRUCTION PROGRAMS Burden Disclosure Notice Page of pages Expires February 28, 2007
1. PROGRAM AGENCY AND ORGANIZATION 2. FEDERAL GRANT OR OTHER IDENTIFYING 3. RECIPIENT ORGANIZATION (Name and complete address, including zip code)
ELEMENT TO WHICH REPORT IS SUBMITTED NUMBER ASSIGNED
4. EMPLOYER IDENTIFICATION 5. RECIPIENT ACCOUNT NUMBER OR I.D. NO. 6. BUDGET PERIOD 7. Mark "X" in Appropriate Box
(Month, Day, Year) New Budget
Beginning Date: Revised Budget. Enter Grant Number in Box 2 above
Ending Date: Date of Budget Revision:
8. FEDERAL RATE SHARING (%) (%) (%) (%) (%) Total
9. PROGRAM ACRONYM
CFDA NUMBER
10. a. Personnel
b. Fringe Benefits
c. Travel
d. Equipment
Object e. Supplies
Class 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 r. Program Income
s. Detail on Indirect Cost
Indirect Type of Rate (mark "X" in one box) Provisional-Final Predetermined Fixed with Carry-Forward
Cost
Rate: % Total Amount of Indirect Cost: Base:
11. Signature of Authorizing Official 12. Name and Title (Type or print) 13. Telephone Number (Area code, Number and Extension) Date Report Submitted
FEMA Form 20-20, FEB 01
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