FEDERAL EMERGENCY MANAGEMENT AGENCY
PROJECT WORKSHEET	O.M.B. No. 3067-0151
Expires April 30, 2001	
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 30 minutes.  The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing and submitting the forms.  You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of the forms.  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).  NOTE:  Do not send your completed form to this address.	
DECLARATION NO.	PROJECT NO.
     	FIPS NO.
     	DATE
     	CATEGORY
     	
FEMA-	    	-DR-	  						
					
DAMAGED FACILITY
     	WORK COMPLETE AS OF:	
		     	:	   	%	
		
APPLICANT
     	COUNTY
     	
LOCATION
     	LATITUDE
     	LONGITUDE
     	
DAMAGE DESCRIPTION AND DIMENSIONS
     	
SCOPE OF WORK
     	
Does the Scope of Work change the pre-disaster conditions at the site?	  Yes	  No
Special Considerations issues 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	
     	     	     	      /      	     	$0.00	
	TOTAL COST	$0.00	
PREPARED BY:       	TITLE:       	
FEMA Form 90-91, SEP 98	REPLACES ALL PREVIOUS EDITIONS.