Subgrant Project Application



FEMA HMA

Subgrant Project Application

|Applicant Information |

| |

|* Name of Applicant |

|  |

| |

|* State |

|MD |

| |

|Congressional District |

|  |

| |

|* Type of Applicant |

|[pic]State Government |

|[pic]Local Government |

|[pic]Indian Tribal Government |

|[pic]Special Governmental District |

|[pic]Private Non-Profit |

|[pic]Other |

| |

|If Private Non-Profit, |

|  |

| |

|Describe the legal status, function, and facilities owned: |

|   |

|   |

|  |

| |

|State Tax Number: (e.g. 11-111111) |

|   |

| |

|Federal Tax Number: (e.g. 11-111111) |

|   |

| |

|If Other, please specify: |

|  |

| |

|* Federal Employer Identification Number (EIN). If Indian Tribe, this is Tribal Identification Number. |

|  |

| |

|What is your DUNS Number? |

| |

| |

|* Are you the application preparer? |

|[pic]Yes   [pic]No |

| |

|* Is the application preparer the Point of Contact? |

|[pic]Yes   [pic]No |

| |

|* Is the applicant delinquent on any Federal debt? |

|[pic]Yes   [pic]No |

| |

| If yes, type explanation: |

| |

| |

| |

| |

|* Community: |

|  |

| |

|Is this a small, impoverished community? |

|(Note: For PDM-C grants, a response to this question is required.) |

|[pic]Yes   [pic]No |

| |

|Contact Information |

| |

|Point of Contact Information |

| |

|Title |

|[pic]Mr. |

|[pic]Ms. |

|[pic]Mrs. |

|[pic]Dr. |

| |

|* First Name |

|  |

| |

|Middle Initial |

| |

| |

|* Last Name |

|  |

| |

|Title |

| |

| |

|* Agency/Organization |

|  |

| |

|* Address 1 |

|  |

| |

|Address 2 |

|  |

| |

|* City |

|  |

| |

|* State |

|  |

| |

|* ZIP |

|  |

| |

|* Phone |

|  |

| |

|Fax |

|  |

| |

|* Email |

| |

| |

|Alternate Point of Contact Information |

| |

|Title |

|[pic]Mr. |

|[pic]Ms. |

|[pic]Mrs. |

| |

|First Name |

|  |

| |

|Middle Initial |

|  |

| |

|Last Name |

|  |

| |

|Title |

|  |

| |

|Agency/Organization |

|  |

| |

|Address 1 |

|  |

| |

|Address 2 |

|  |

| |

|City |

|  |

| |

|State |

|  |

| |

|ZIP |

|  |

| |

|Phone |

|  |

| |

|Fax |

|  |

| |

|Email |

|  |

| |

|Community Profile |

| |

|  |

| |

| |

| |

| |

|Mitigation Plan Information |

| |

|* Is the entity that will benefit from the proposed activity covered by a current |

|FEMA-approved multihazard mitigation plan in compliance with 44 CFR Part 201? |

|[pic]Yes   [pic]No    [pic]Not Known |

| |

|If yes, please answer the following: |

| |

|* What is the name of the plan? |

| |

| |

|* What is the type of plan? |

|[pic]Local MultiJurisdictional Multihazard Mitigation Plan |

|[pic]Local Multihazard Mitigation Plan |

|[pic]Tribal (Local) MultiJurisdictional Multihazard Mitigation Plan |

|[pic]Tribal (Local) Multihazard Mitigation Plan |

| |

|* When was the current multihazard mitigation plan approved by FEMA? |

|  |

| |

|* Describe how the proposed activity relates to or is consistent with the FEMA-approved mitigation plan. |

|  |

| |

| |

| |

|If no or not known, please answer the following: |

| |

|* Does the entity have any other mitigation plans adopted? |

|[pic]Yes   [pic]No   [pic]Not Known |

| |

|  |

|If yes, please provide the following information. |

| |

| |

| |

|Plan Name |

|Plan Type |

|Date Adopted |

|Attachment |

| |

|  |

|  |

|  |

|  |

| |

|  |

|  |

|  |

|  |

| |

|  |

|  |

|  |

|  |

| |

|* Does the State/Tribe in which the entity is located have a current FEMA-approved mitigation plan in compliance with 44 CFR Part 201? |

| [pic]Yes  [pic]No |

| |

|If yes, please answer the following: |

| |

|* What is the name of the plan? |

|   |

| |

|* What is the type of plan? |

|[pic]Enhanced State Multi-hazard Mitigation Plan |

|[pic]Enhanced Tribal Multi-hazard Mitigation Plan |

|[pic]Standard State Multi-hazard Mitigation Plan |

|[pic]Standard Tribal Multi-hazard Mitigation Plan |

|[pic]State Mitigation Plan - Pre DMA2000 |

| |

|* When was the current mitigation plan approved by FEMA? |

|   |

| |

|* Describe how the proposed activity relates to or is consistent with the State/Tribe's FEMA-approved mitigation plan. |

| |

| |

| |

|  |

| |

|Mitigation Activity Information |

| |

|* What type of activity are you proposing? (Please choose activities from Appendix A below). |

| |

|  |

| |

| |

| |

| |

|If you selected Other or Miscellaneous, above, please specify: |

| |

|  |

| |

|* Title of your proposed activity(should include the type of activity and location): |

| |

|  |

| |

|* Are you doing construction in this project? |

| |

|[pic]Yes   [pic]No |

| |

|Hazard Information |

| |

|Problem Description: please describe the problem to be mitigated. Include the geographic area in your description. |

| |

|  |

| |

| |

| |

| |

| |

|Enter the Latitude and Longitude coordinates for the project area. |

| |

|Latitude: |

|  |

| |

|Longitude: |

|  |

| |

|Hazards |

| |

|Select hazards to be mitigated: |

|[pic]Biological |

|[pic]Chemical |

|[pic]Civil Unrest |

|[pic]Coastal Storm |

|[pic]Crop Losses |

|[pic]Dam/Levee Break |

|[pic]Drought |

|[pic]Earthquake |

|[pic]Fire |

|[pic]Fishing Losses |

|[pic]Flood |

|[pic]Freezing |

|[pic]Human Cause |

|[pic]Hurricane |

|[pic]Land Subsidence |

|[pic]Mud/Landslide |

|[pic]Nuclear |

|[pic]Other |

|[pic]Severe Ice Storm |

|[pic]Severe Storm(s) |

|[pic]Snow |

|[pic]Special Events |

|[pic]Terrorist |

|[pic]Tornado |

|[pic]Toxic Substances |

|[pic]Tropical Cyclones |

|[pic]Tsunami |

|[pic]Typhoon |

|[pic]Volcano |

|[pic]Windstorms |

| |

|If other hazards, please specify |

|  |

| |

|FIRM Information |

| |

|* Is the project located within hazard area? |

|[pic]Floodway |

|[pic]Floodplain |

|[pic]Other identified high hazard area |

|[pic]No |

| |

|If other identified high hazard area, please specify: |

| |

| |

|*Is there a Flood Insurance Rate Map (FIRM) or Flood Hazard Boundary Map (FHBM) available for your project area? |

|If you have selected Yes, the following three fields are required: |

|[pic]Yes     [pic]No |

| |

|Enter FIRM Panel Number: |

| [pic]check if Not Applicable |

| |

|Mark your project site on the FIRM/FHBM (even if it is out of the floodplain) |

|[pic]Electronic map attached |

|[pic]Hard copy provided |

|[pic]Not Applicable |

| |

|Select Flood Zone Designation |

|[pic]C, X [pic]V0 |

|[pic]B, X [pic]AH |

|[pic]N [pic]V1-30, VE |

|[pic]AR [pic]V |

|[pic]A99 [pic]E |

|[pic]A1-30, AE [pic]M |

|[pic]A [pic]D |

|[pic]A0 [pic]P |

| |

|Scope of Work |

| |

|* What are the goals and objectives of this activity? |

| |

| |

| |

| |

| |

|* Briefly describe the need for this activity. |

| |

| |

|  |

| |

|* Describe the problems this activity will address. |

| |

| |

|  |

| |

|*Describe the methodology for implementing this activity. |

| |

| |

|  |

| |

|Enter Work Schedule |

| |

|Description Of Task |

|Starting Point |

|Unit Of Time |

|Duration |

|Unit Of Time |

|Work Complete By |

| |

|  |

|  |

|  |

|  |

|  |

|  |

| |

|  |

|  |

|  |

|  |

|  |

|  |

| |

|  |

|  |

|  |

|  |

|  |

|  |

| |

|* Estimate the total duration of the proposed activity: |

|  |

|[pic]Day(s) |

|[pic]Week(s) |

|[pic]Month(s) |

|[pic]Year(s)   |

| |

|Properties |

| |

|Property Owner's Name |

|Damaged Property Address |

|City |

|State |

|Repetitive |

|Loss |

|Zip Code |

| |

|  |

|  |

|  |

|  |

|  |

|  |

| |

|  |

|  |

|  |

|  |

|  |

|  |

| |

|  |

|  |

|  |

|  |

|  |

|  |

| |

| Damaged Property Address: |

| |

|* Address line 1 |

|Street Name: |

|Street Type: |

| |

|Address line 2 |

|Unit Type: |

|Number: |

| |

|* City |

|  |

| |

|* County |

| |

| |

|* State |

|  |

| |

|* ZIP |

|  |

| |

|Owner Information: |

|If the owner is an organization, then split this information in the First and Last Name. |

| |

|* First Name |

| |

| |

|Middle Name |

| |

| |

|* Last Name |

| |

| |

|Phone |

|Home |

|Office |

| |

|  |

|  |

| |

|Cell |

|Other |

| |

|  |

|  |

| |

| |

| |

|[pic]Owner's Mailing Address (check if this address is the same as Property Address above): |

| |

|Address line 1 |

|Street Number: |

|Direction: |

|Street Name: |

|Street Type: |

| |

|Address line 2 |

|Unit Type: |

| |

|Other (PO Box, Route, etc) |

|  |

| |

|City |

|  |

| |

|State |

|  |

| |

|ZIP |

|  |

| |

|*Does this property |

|have other co-owners |

|or holders of recorded interest? |

|[pic]Yes    [pic]No  |

| |

|If Yes, Enter Co-owner or Owner of Property Interest Information: |

|If the co-owner is an organization, then split this information in the First and Last Name. |

| |

|*First Name |

| |

| |

|Middle Name |

| |

| |

|*Last Name |

| |

| |

|Phone |

|Home |

|Office |

| |

|  |

|  |

| |

|Cell |

|Other |

| |

|  |

|  |

| |

| |

| |

|Co-owner's Mailing Address: |

| |

|[pic]Owner's Mailing Address    [pic]Property Address    [pic]None |

| |

|Address line 1 |

|Street Number:: |

|Street Name: |

| |

|Address line 2 |

|Unit Type: Number: |

| |

|Other (PO Box, Route, etc) |

| |

| |

|City |

|  |

| |

|State |

|  |

| |

|ZIP |

|  |

| |

|Property Information: |

| |

|Age of structure (year built) |

| |

| |

|SHPO Review |

|[pic]Yes |

|[pic]No |

|[pic]Not Applicable |

|[pic]Unknown |

| |

|SHPO |

|Review Date |

|  |

| |

|Structure Type |

|[pic]2-4 Family |

|[pic]Manufactured Home |

|[pic]Multi-Family Dwelling - 5 or More Units |

|[pic]Non-residential - Private |

|[pic]Non-residential - Public |

|[pic]Other (Specify in Comments) |

|[pic]Single Family |

|[pic]Vacant Land |

| |

|Other |

|  |

| |

|Foundation type |

|[pic]Basement |

|[pic]Crawl Space |

|[pic]Elevated on Piers, Piles, Posts or Columns |

|[pic]Other (Specify in Comments) |

|[pic]Slab on Grade |

|[pic]Vacant Land |

| |

|Other |

|  |

| |

|Basement |

|[pic]Yes   [pic]No |

| |

|Type of Residence |

|[pic]Not Applicable |

|[pic]Other |

|[pic]Owner Occupied- Secondary Residence |

|[pic]Owner Occupied-Principal Residence |

|[pic]Rental |

| |

|Other |

|  |

| |

|Parcel Number |

| |

| |

|Property Tax Identification Number |

| |

| |

|Latitude |

| |

| |

|Longitude |

| |

| |

|Does this property have a NFIP Policy Number? |

|(Note: For SRL grants, a response to this question is required.) |

|[pic]Yes   [pic]No |

| |

|Number |

| |

| |

|Insurance Company |

| |

| |

|* Select hazards to be mitigated: |

|[pic]Biological |

|[pic]Chemical |

|[pic]Civil Unrest |

|[pic]Coastal Storm |

|[pic]Crop Losses |

|[pic]Dam/Levee Break |

|[pic]Drought |

|[pic]Earthquake |

|[pic]Fire |

|[pic]Fishing Losses |

|[pic]Flood |

|[pic]Freezing |

|[pic]Human Cause |

|[pic]Hurricane |

|[pic]Land Subsidence |

|[pic]Mud/Landslide |

|[pic]Nuclear |

|[pic]Other |

|[pic]Severe Ice Storm |

|[pic]Severe Storm(s) |

|[pic]Snow |

|[pic]Special Events |

|[pic]Terrorist |

|[pic]Tornado |

|[pic]Toxic Substances |

|[pic]Tropical Cyclones |

|[pic]Tsunami |

|[pic]Typhoon |

|[pic]Volcano |

|[pic]Windstorms |

| |

| |

| |

| |

| |

|Other |

|  |

| |

|* Damage Category |

|[pic]0-49% Damaged |

|[pic]100% Damaged |

|[pic]50-99% Damaged |

|[pic]Not Applicable |

| |

|Pre Event Fair Market Value |

| |

| |

|Benefit Cost Analysis Performed |

|[pic]Yes [pic]Not Applicable |

|[pic]No [pic]Unknown |

| |

| |

|Benefit Cost Ratio |

| |

| |

|Repetitive Loss Structure |

|[pic]Yes |

|[pic]No |

|[pic]Unknown |

| |

|Property Locator Number |

| |

| |

|Number of Losses |

|[pic]2-3 Losses Cumulatively > building Fair Market Value |

|[pic]2-3 Losses Cumulatively ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download