Form FEMA Form 090-0-1 FEMA Form 090-0-1 Certification of Eligibility for Community Disaster Loan

O.M.B. No. 1660-0083
Expires June 30, 2012

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

CERTIFICATION OF ELIGIBILITY FOR COMMUNITY DISASTER LOANS
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 2.5 hours 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. This collection of
information is required to obtain or retain benefits. You are not required to respond to this collection of information unless it displays a valid OMB control
number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections
Management, Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005
Paperwork Reduction Project (1660-0083). Note: Do not send your completed form to this address.
PRIVACY NOTICE
This information is being collected under the authority of Section 417 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law
93-288, as amended, (42 U.S.C. 5121-5207), and 44 CFR, § 206.364. DHS/FEMA will use this information to provide operational funding to help local
governments that have incurred a significant loss in revenue, due to a major disaster, that has or will adversely affect their ability to provide essential
municipal services. The information will be used by and disclosed to DHS personnel and contractors, state government officials, or other agents who
need the information to assist in activities related to disaster relief. In addition, the information on this form may be disclosed as generally permitted under
the Freedom of Information Act, as amended (5 U.S.C. § 552). Furnishing this information is voluntary; however, failure to furnish the requested
information may delay or prevent the completion of your loan application and disbursement.

YES

1. Does State law prohibit your municipality from incurring the indebtedness from a federal loan?
2. Has the disaster cause revenue loss greater than 5% of total revenue estimated for the fiscal year of the
disaster or the following fiscal year?
3. Has the loss of revenue or the increase in disaster-related un-reimbursable expenses adversely affected the
level and/or the categories of essential municipal services provided prior to the disaster? If yes, explain.
4. Are there insufficient funds to meet current fiscal year operating requirements?
If yes, what measures are you taking to meet financial obligations?
5. Is cash or other liquid assets available from the previous fiscal year? If yes, how long
will the cash or liquid assets last given your current financial projections?
6. Were revenue producing business displaced due to property destruction?
7. Have you reduced or eliminated essential municipal services?
If no, do you plan on doing this?
8. Are you in danger of municipal insolvency?
By signing this certificate, the applicant representative hereby confirms the following:
- All statements are made truthfully, as fairly and accurately as possible.
- All statements are in accordance with any federal, state, and local laws, standards, and regulations.
SIGNATURE OF APPLICANT REPRESENTATIVE

DATE

NAME OF APPLICANT REPRESENTATIVE

TITLE

NAME OF APPLICANT PARISH/COUNTY

STATE

APPLICANT REPRESENTATIVE CONTACT EMAIL

PHONE NO.

FEMA Form 090-0-1, JUL 09

PREVIOUSLY FEMA Form 90-143

NO