* THIS FORM MUST BE COMPLETED IN ORDER TO RECEIVE FINANCIAL ASSISTANCE FROM THE STATE OF ARIZONA *
AUGUST 2001 Form # AZ PA 204-2
ARIZONA DIVISION OF EMERGENCY MANAGEMENT
APPLICATION FOR STATE ASSISTANCE
SUBMIT TO: DISASTER RECOVERY OFFICE
ARIZONA DIVISION OF EMERGENCY MANAGEMENT
5636 EAST MCDOWELL ROAD, DFO BLDG. 5507
PHOENIX, ARIZONA 85008
1.
A disaster situation exists in __________________________ due to ______________________
causing damage to _____________________________________________________________
_____________________________________________________________________________
___________________________________ occurring at (date/time) _____________________ .
2.
Action has already been taken to meet the emergency at an estimated cost of $ _____________ .
These expenditures have accomplished the following:
___ Debris Removal ___ Temporary Repairs
___ Evacuation ___ Other _____________________________
___ Traffic Control __________________________________
3.
The additional funds required to accomplish minimum essential work are estimated to be
$ ________________. The additional funds will permit the following project to be completed:
___ Repair Roads, Streets, and Bridges ___ Utility Repairs
___ Building Repairs or Replacement ___ Other ____________________________
___ Equipment Repair or Replacement _________________________________
4.
Temporary expenditures or alternate solutions could be accomplished with $ _______________ of local funds by
deferring or canceling:
___ Project (list) _______________________ ___ Not a Viable Option
___ Capital Expenditures ________________ ___ Other (List) ________________________
5.
Please attach a resolution of emergency along with a statement of availability of funds for response and recovery
emergency work, as it relates to the overall financial condition (budget) of jurisdiction. The Statement to be
executed and signed by an appropriate official. You will also need to include a copy of your annual budget.
6.
Comments ____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7.
Signed: _____________________________________________________________________________________
Title: ______________________________________________________________________________________
Date: ______________________________________________________________________________________
APPROVED
8.
ADEM
DENIED
______________________________________ ______________
ADEM AUTHORIZED SIGNATURE DATE
