Form FEMA Form 116-0-1 FEMA Form 116-0-1 Promissory Note

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

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

PROMISSORY NOTE

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 4 hours per response. The burden estimates includes time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is
required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this
form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the 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 questionnaire 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.
PART I: COMMUNITY DISASTER LOAN
1. NAME AND ADDRESS OF BORROWER

2. TELEPHONE NUMBER
3. LOAN NUMBER

,

DATE

(herein called "Borrower") promises to pay to the Order of the United States of America, acting through the Federal Emergency
Management Agency, (herein called the "Government") at its office in
The principle sum
Of
rate of

dollars ($
percent (

), Plus interest on the unpaid principal balance at the

%) per annum. The principal and interest less such as may be canceled pursuant to

Section 417 of the Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288, as amended and implementing
regulations are due on

Unless the term of this note is extended in the sole discretion of the

Government, except that prepayments may be made as provided below.
The loan shall be paid in increments to Borrower as requested by Borrower and approved by Government. Interest shall be charged on
each loan increment from the actual date of payment by the Government.
Every repayment made on this loan shall be applied first to interest and then to principal.
Prepayments of scheduled installments, or any portion thereof, may be made at any time at the option of Borrower. Such payments shall
be applied to the installments last to become due under this note and shall not affect the obligation of Borrower to pay the remaining
installments.
Any cost incurred by the government in collecting this note shall be added to the unpaid balance of the loan, bear interest at the same
rate as this loan, and are immediately due without demand.
The government may extend, or renew, this note without affecting any other rights it has against the Borrower or any other party.
Borrower agrees to use this loan solely for purposes authorized by the Government.
In the event of default on this note by the Borrower, the Department of Homeland Security/Federal Emergency Management Agency will
take action to recover the outstanding principal plus related interest under Federal Debt collection authorities, including administrative
offset against other Federal funds due the Borrower and/or referral to the Department of Justice for Judicial enforcement and collection.
FEMA Form 116-0-1, JUL 09

PREVIOUSLY FEMA Form 90-6

DEFAULT hereunder shall constitute default under any other instrument evidencing a debt of borrower owing to or insured by
the Government or securing or otherwise relating to such a debt; and default under any such other instrument shall constitute
default hereunder. UPON ANY SUCH DEFAULT, the Government at its option may declare all or part of such indebtness
immediately due and payable.
This note is given as evidence of a loan to Borrower made by the Government pursuant to section 417 of the Stafford Act
(Public Law 93-288, as amended) and Federal Emergency Management Agency Regulation 44 CFR 206, Subpart K.

(SEAL)
ATTEST:

(Signature of Attesting Official)

(Name of Borrower)

(Title of Attesting Official)

(Signature of Executive Official)
(Title of Executive Official)
(Post Office Box No. or Street Address)
(City, State, and Zip Code)
PART II - STATE CO-SIGNER

Is State co-signing this note?

Yes

If Yes, State must complete Part II.

No

If No, attach FEMA Form 90-100, Collateral Security.

ATTEST:

(Signature of Attesting Official)

Name of State Co-Signer)

(Title of Attesting Official)

(Signature of Co-Signer)

(Title of State Oficial)

SEAL:

PART III - SCHEDULE OF LOAN INCREMENTS TO BE DISBURSED TO BORROWER
AMOUNT

DATE

AMOUNT

(1) $

(6) $

(2) $

(7) $

(3) $

(8) $

(4) $

(9) $

(5) $

(10) $
Text

PAY TO THE ORDER OF:
PART IV - RECOVERY DIVISION, PUBLIC ASSISTANCE BRANCH AUTHORIZATION
TYPED NAME AND TITLE (Authorizing Official)

SIGNATURE

DATE