Form FEMA Form 090-0-2 FEMA Form 090-0-2 Application for Community Disaster Loan

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

See Paperwork
Burden Disclosure
Notice on page 2

APPLICATION FOR FEDERAL ASSISTANCE
(Application for Community Disaster Loan)
1. TYPE OF SUBMISSION
(Application)

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

2. DATE SUBMITTED

APPLICANT IDENTIFIER

3. DATE RECEIVED BY STATE

STATE APPLICATION IDENTIFIER

4. DATE RECEIVED BY FEDERAL
AGENCY

FEDERAL IDENTIFIER

(Preapplication)

Construction
Loan

Construction

Non-Construction

Non-Construction

5. APPELLATION INFORMATION
a. LEGAL NAME

b. ORGANIZATIONAL UNIT

c. ADDRESS (Give city, county, state, and zip code)

d. NAME AND TELEPHONE NUMBER OF THE PERSON TO BE
CONTACTED INVOLVING THIS APPLICATION (Give area code)

6. EMPLOYER IDENTIFICATION NUMBER (EIN)
8. TYPE OF APPLICATION
LOAN
NEW

7. TYPE OF APPLICANT (Enter appropriate letter in box) *
(* First see 44 CFR 206.363(a))
a. State
b. County
c. Municipal
d. Township
e. Interstate
f. Intermunicipal
g. Special District

h. Independent School Dist.
i. State Controlled Institution of Higher Learning
j. Private University
k. Indian Tribe
l. Individual
m. Profit Organization
n. Other (Specify)

9. NAME OF FEDERAL AGENCY

REVISION
If Revision, enter appropriate letter(s) in boxe(s)
a. Increase
c. Increase Duration

11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:

Other (Specify):

APPLICATION FOR COMMUNITY DISASTER LOAN
START DATE

b. Decrease Award
d. Decrease Duration

10. CATALOG OF FEDERAL DOMESTIC
ASSISTANCE NUMBER:
8 3
5
1 6
TITLE: DISASTER ASSISTANCE
12. AREAS AFFECTED BY THE PROJECT (Cities, counties, states, etc.)

FEDERAL EMERGENCY MANAGEMENT AGENCY

13. PROPOSED PROJECT

CONTINUATION

LOCAL GOVERNMENT

14. CONGRESSIONAL DISTRICT OF:
a. APPLICANT

ENDING DATE

b. PROJECT

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?

15. ESTIMATED FUNDING
a. Federal

$

.00

a. YES. This application/preapplication was made available to the state executive order
12372 process for review on:

b. Applicant

$

.00

Date:

c. State

$

.00

b. NO.

d. Local

$

.00

e. Other

$

.00

Review waived per FEMA - State agreement for major disaster

f. Program

$

.00

17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBIT?

g. TOTAL

$

.00

Program is not covered by E. O. 12372
Or program has not been selected by state for review

a. YES, (If "YES" attach an explanation)

NO

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT. THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE
ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. TYPED NAME OF AUTHORIZED REPRESENTATIVE

b. TITLE

d. SIGNATURE OF AUTHORIZED REPRESENTATIVE

FEMA Form 090-0-2, JUL 09

c. TELEPHONE No.
DATE

PREVIOUSLY FEMA Form 90-7

Certification
A. The State certifies that the applicant possesses the legal authority to apply for the loan in the amount requested.
The Applicant Certifies
B. That it possesses the legal authority to apply for the loan amount requested.
C. That a resolution, motion or similar action has been duly adopted as an official act of the applicant, city counsel or other governing body, authorizing the
filling of the loan application, including all understandings and assurances contained therein, and directing and authorizing the person identified as the official
representative of the applicant to act in connection with the application and to provide such additional information as may be requested.
D. That (to the best of his/her knowledge and belief) the Community Disaster Loan herein requested is eligible in accordance with the criteria contained in
44 Code of Federal Regulation, Part 206, and applicable FEMA/EP&RD (DAP) Handbooks and guidelines.
E. That this is the legal entity responsible under law for the repayment of the Community Disaster Loan and interest thereon or accepts such responsibility.
F. That all information given by it herein is, to the best of my knowledge and belief, true and correct.
Assurances
G. The States agree to provide technical assistance in review of records of the Applicant which provide the basis for the application for the loan and for loan
cancellation. The State further agrees to provide technical assistance in processing and administering the loan
The Applicant Certifies
H. That it complies with all Federal statues relating to nondiscrimination. These include but are not limited to: (1) Title VI of the Civil Rights Act of 1964 (P.L.
88-352) which prohibits discrimination on the basis of race, color or national origin; (2) Title IX of the Education Amendment of 1972, as amended (20 U.S.C.
1681-1683, and 1685-1686) which prohibits discrimination on the basis of sex; (3) Section 504 of the Rehabilitation Act of 1973, as amended (29) U.S.C.
794) which prohibits discrimination on the basis of handicaps; (4) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107) which prohibits
discrimination on the basis of age (5) the Drug Abuse Office and Treatment Act of 197 2 (P.L. 93-255) as amended, relating to nondiscrimination on the
basis of drug abuse; (6) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L.91-616) as amended,
relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (7) 523 and 527 of the Public Health Service Act of 19 12 (42 U.S.C 290 dd-3 and
290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse patients records; (8) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et.
seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (9) any other nondiscrimination provision the specific statue(s)
under which application for Federal assistance is being made; and (10) the requirements on any other nondiscrimination Statue(s) which may apply to the
application.
I. That this assurance is given in consideration of and for the purpose of obtaining any and all Federal grants, loans reimbursements, advances, contracts,
property, discounts or other Federal financial assistance extended after the date hereof to the Applicant by EP&RD/FEMA, that such Federal assistance will
be extended in reliance on the representations an agreements made in the full assurance and that the United States shall have the right to seek judicial
enforcement of this assurance. This assurance is binding on the Applicant, its successors, transferrers, and assignees, and the person or persons whose
signatures appears on the reverse are authorized to sign this assurance on behalf of the Applicant.
J. That it give the awarding agency, the Comptroller General of the United States, and if appropriate, the State, through any authorized representative,
access to and the right to examine all records, books, papers, or documents related to the assistance, and will establish a proper accounting system in
accordance with generally accepted accounting standards or agency directives.
K. That the loan funds do not duplicate funding provided from any other source.
L. That it causes to be performed the required finical and compliance audits in accordance with the Single Audit Act of 1984.

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1 hour 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 a valid OMB control number is
displayed on this form. 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,
and Paperwork Reduction Project (1660-0083). NOTE: Do not send your completed form to the above 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.

I. ESTIMATE OF REVENUE LOSS AND DISASTER-RELATED EXPENSES
(1)
FISCAL YEAR
PRECEDING
DISASTER

(2)
FISCAL YEAR
(FY) OF
DISASTER

20

(3)
FIRST
SUCCEEDING

20

(4)
SECOND
SUCCEEDING

20

(5)
THIRD
SUCCEEDING

20

(6)
TOTAL
(2 + 3 + 4 + 5)

20

A. Annual Operating Budget 1/

B. Estimated Revenue Loss 2/
C. Disaster Related Expenses 3/
D. Total (B + C)
E. Percent (D/A X 100)
F. 25% OF (A)
1/Provide

2/Provide

copy of Operating Budget for fiscal year (FY) of disaster, and explanation for significant future FY increases/decreases.
supporting information indicating how figures in the revenue/expense estimates were developed.

AMOUNT OF LOAN REQUESTED (Not to exceed
25% of Annual Operating Budget for Disaster Year)

FROM

DURATION OF LOAN
TO

APPLICANT'S FISCAL YEAR ENDS

II. OPERATIONAL RESULTS (For Year of Disaster * and Prior Three Fiscal Years)
THIRD PRIOR

SECOND PRIOR

20

FISCAL YEAR PROCEEDING
DISASTER 20

20

FISCAL YEAR (FY) OF
DISASTER 20

A. Cash Balance (or Deficit) from
Previous Fiscal Year(include
investments)
B. Cash Balance (or Deficit) at End of
Fiscal Year
C. Liabilities at End of Fiscal Year
D. Ratio of B. to C.
E. Attach audited financial statements for each of the four prior fiscal years
III. DEBT HISTORY
A. Postponements and Defaults. Have there been postponements or defaults in any payments of principal or interest on past or current indebtness by the
applicant?
If, yes, explain the circumstances, corrective action taken and pertinent dates. Attach explanation.
YES
NO
B. Outstanding bonded indebtedness. List below each medium and long-term indebtedness currently outstanding and such short-term indebtedness as may
have a bearing on the loan requested. If for outstanding indebtedness of a particular series, there are two or more interest rates, show the average interest rate
on obligations still outstanding.
NAME OF
OUTSTANDING INDEBTNESS

AMOUNT OUTSTANDING
AS OF

DATE
OF ISSUE

20

AVERAGE
INTEREST RATE

TOTAL TERM
OF ISSUE

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

20

%

Yrs.

C. Federal Loans. If any bonds or other instruments of indebtness are presently held by the U.S. Government, specify the agency and
the instruments of indebtness.

IV. TAX ASSESSMENT (FY of Disaster + 3 Prior FY's)
A. PROPERTY ASSESSMENT AS OF (Month, day, year)

B. PAYMENT AGAINST ASSESSMENT (Month, day, year)

THIRD PRIOR

SECOND PRIOR

FY 20

C. Real Property Taxes

FY 20

FISCAL YEAR
PRECEDING DISASTER
FY 20

FISCAL YEAR (FY) OF
DISASTER
FY 20

1. Market Value ($)
2. Assessment Ratio ( % )
3. Valuation ( $ = 1 x 2)
4. Tax Rate ( $ = 3 x 4)
5. Tax Levy ( $ = 3 x 4)
6. Taxes Collected
V. OTHER INFORMATION
A. Other Federal Assistance. Are you requesting or receiving assistance from the Federal Government for a reason which is similar to the one for which
assistance is requested in this application?
If yes, provide the name of the
other agency and project number
B. Has the loan been approved by the City Counsel?
YES
NO
If yes, give date of loan
YES

NO

C. Does a State agency have to approve the proposed debt?
If yes, identify the agency and
briefly explain its authority.
D. Is this loan requested for $
within the applicant's ceiling for financial obligations fixed by law or by local government body?
YES

NO

YES

NO

If No, attach explanation.

E. Name and Address of Applicant's Chief Fiscal Officer (Include zip code)

Title of Applicant's Chief Fiscal Officer

PHONE No. (Include area code)

CERTIFICATION
The Applicant certifies to t e best of his/her knowledge and belief that the debt in the loan application is correct and that the loan is legal and has been duly
authorized by the governing body of the applicant. (Penalties for false and misleading information are covered by Federal laws)
NAME AND TITLE OF APPROVING OFFICIAL

DATE

SIGNATURE

FORWARDED
NAME AND TITLE OF APPROVING OFFICIAL (Governor's Authorized
Authorized Representative)

FOR FEMA USE ONLY

RECOMMENDED:

NAME AND TITLE OF APPROVING OFFICIAL (FEMA Regional Dir.)

APPROVAL

DISAPPROVAL

SIGNATURE

DATE

DISAPPROVED

APPROVED IN THE AMOUNT OF $

NAME AND TITLE OF APPROVING OFFICIAL (EP&RD Regional Dir.)

DATE

SIGNATURE

SIGNATURE

DATE