FEDERAL EMERGENCY MANAGEMENT AGENCY
REQUEST FOR PUBLIC ASSISTANCE	O.M.B. No. 3067-0151
Expires April 30, 2001	
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 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.	
APPLICANT (Political subdivision or eligible applicant.)
     	DATE SUBMITTED
     	
COUNTY (Location of Damages.  If located in multiple counties, please indicate.)
     	
APPLICANT PHYSICAL LOCATION	
STREET ADDRESS
     	
CITY
     	COUNTY
     	STATE
  	ZIP CODE
     	
MAILING ADDRESS (If different from Physical Location)	
STREET ADDRESS
     	
POST OFFICE BOX
     	CITY
     	STATE
  	ZIP CODE
     	
Primary Contact/Applicant’s Authorized Agent	Alternate Contact	
NAME
     	NAME
     	
TITLE
     	TITLE
     	
BUSINESS PHONE
     	BUSINESS PHONE
     	
FAX NUMBER
     	FAX NUMBER
     	
HOME PHONE (Optional)
     	HOME PHONE (Optional)
     	
CELL PHONE
     	CELL PHONE
     	
E-MAIL ADDRESS
     	E-MAIL ADDRESS
     	
PAGER & PIN NUMBER
     	PAGER & PIN NUMBER
     	
Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?	  Yes	  No	
Private Non-Profit Organization?	  Yes	  No	
If yes, which of the facilities below best describe your organization?	     		
Title 44 CFR, part 206.221(e) defines an eligible private non-profit facility as: “… any private non-profit educational, utility, emergency, medical or custodial care facility, including a facility for the aged or disabled, and other facility providing essential governmental type services to the general public, and such facilities on Indian reservations.”  “Other essential governmental service facility” means museums, zoos, community centers, libraries, homeless shelters, senior citizen centers, rehabilitation facilities, shelter workshops and facilities which provide health and safety services of a governmental nature.  All such facilities must be open to the general public.
Private Non-Profit Organizations must attach copies of their Tax Exemption Certificate and Organization Charter or By-Laws.  If your organization is a school or educational facility, please attach information on accreditation or certification.	
Official Use Only:    FEMA-	     	-DR-	     	-	     	FIPS #	     	Date Received:	     	
	
FEMA Form 90-49, SEP 98	REPLACES ALL PREVIOUS EDITIONS.