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Submitting a Public Assistance Funding Request for COVID-19 (FEMA)

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Last Updated: April 10, 2020 1
Submitting a Public Assistance
Funding Request for COVID-19
FEMA Public Assistance COVID-19 Streamlined Project Application
FEMA developed this COVID-19 streamlined project application to simplify
the application process for Public Assistance funding under the COVID-19
pandemic declarations. This document includes the project application
and instructions for how the Applicant should complete and submit the
application to the Recipient and FEMA.
Overview
FEMA may provide funding to eligible Applicants for costs related to
emergency protective measures
1
conducted as a result of the COVID-19
pandemic. Emergency protective measures are activities conducted to
address immediate threats to life, public health, and safety. Eligible
Applicants may submit funding requests to the Recipient and FEMA
through the Public Assistance Grants Portal. FEMA provides funding
through Recipients to eligible Applicants.
Prerequisites
Prior to submitting this project application, Applicants must submit and
receive approval of a Request for Public Assistance. To submit a request,
visit the Public Assistance Grants Portal at grantee.fema.gov.
Public Assistance Funding Considerations
Public Assistance funding is subject to a cost share: The assistance FEMA
provides through its Public Assistance program is subject to a cost share.
The federal share is not less than 75 percent of eligible costs. The federal
cost share may be increased in limited circumstances if warranted. The
Recipient determines how much of the non-federal share the Applicant
must fund.
Public Assistance cannot duplicate funding from another federal source:
Some activities may be eligible for funding through both FEMA and other federal agency funding sources
for COVID-19 including the U.S. Department of Health and Human Services’ Centers for Disease Control
and Prevention (CDC) and Office of the Assistant Secretary for Preparedness and Response (ASPR). The
Applicant should not request funding for activities where the costs have been or will be claimed from
another federal funding source.
2
Some activities may be completed through direct federal assistance: Some eligible activities may be
completed directly by the Federal Government rather than provided as financial assistance to Applicants to
1
The latest updated guidance on emergency protective measures eligible for Public Assistance reimbursement for COVID-19
can be found at https://www.fema.gov/coronavirus.
2
Including any costs that have been or will be claimed through another funding source will delay the Recipient’s and FEMA’s
processing of this funding request. If FEMA or the Recipient later determines the Applicant requested funding for activities
where costs were funded by another federal agency, FEMA may de-obligate all funding until the Applicant can specifically
demonstrate that duplicate funding was not provided. If another federal agency has denied a funding request, the Applicant
may submit the funding request to the Recipient and FEMA for consideration.
Grants Portal
is the system used by
Recipients and Applicants
to manage PA grant
applications.
Recipients
are state, tribal, or
territorial entities that
receive and administer
Public Assistance federal
awards..
Applicants
are state, tribal, territorial,
or local governments or
private non-profit entities
that may request and
receive subawards under
a Recipient’s award.
Projects & Subawards
Projects are groupings of
activities that become a
subaward under the
Recipient’s award when
approved.
Last Updated: April 10, 2020 2
complete those activities. If an Applicant does not have the capacity to directly complete the activity or
oversee activity completion through contract or mutual aid, the Applicant may request that FEMA or
another federal agency directly conduct the activity. Applicants seeking direct federal assistance should
not use this project application but instead request assistance from the FEMA Regional Administrator
through the Recipient’s emergency manager.
For more guidance: The following FEMA guidance defines activities and associated costs that are eligible
for Public Assistance funding:
• FEMA’s Public Assistance Program and Policy Guide (PAPPG)
• FEMA Fact Sheet: Coronavirus (COVID-19) Pandemic: Eligible Emergency Protective Measures
• FEMA Fact Sheet: Coronavirus (COVID-19) Pandemic: Emergency Medical Care
• FEMA Fact Sheet: Public Assistance: Non-Congregate Sheltering Delegation of Authority
• FEMA Fact Sheet: Coronavirus (COVID-19) Pandemic: Non-Congregate Sheltering- FAQ
• FEMA Fact Sheet: Procurement Under Grants: Under Exigent or Emergency Circumstances
• FEMA Fact Sheet: Coronavirus (COVID-19) Pandemic: FEMA Assistance for Tribal Governments
• FEMA Fact Sheet: Coronavirus (COVID-19) Pandemic: Private Nonprofit Organizations
What information is required?
Applicants will need the following information about their activities and costs to complete this form:
• A description of the activities including when, where, and by whom the activities were completed or
will be completed.
• A summary of how much the activities cost, including costs associated with contract, labor,
equipment, supply, material, and other cost types.
• Documentation supporting the activities completed and costs claimed, as detailed below.
• Certification of compliance with federal, state, tribal, territorial, and local laws and regulations.
How does the Applicant complete this project application?
Applicants will complete and submit this project application online in the FEMA Public Assistance Grants
Portal. FEMA will not accept paper submissions of this project application. The application is being
provided to Applicants and Recipients in paper form here to provide guidance on what information FEMA
will require from Applicants if they seek reimbursement for COVID-19 related activities.
FEMA will process each project application submitted as a separate funding request. To reduce funding
delays and maximize the Applicant’s administrative flexibilities to track costs, Applicants should generally
report all activities on one project application. However, submitting a separate project application for
distinct activities or time periods is advisable in certain scenarios:
• When an Applicant needs to be reimbursed immediately and cannot wait to gather all information
to submit a full claim for all their activities and costs, the Applicant may:
o Request expedited funding to receive an award of 50% of the total cost based on limited
documentation;
3
or
o Limit an initial project application to certain activities or an initial time period and follow up
later with an additional project application for other activities or time periods.
4
• Certain activities may require FEMA to complete a more in-depth environmental or historic
preservation review, for example: ground disturbance, hazardous materials, modifications to
buildings, or new construction. For these activities, the Applicant should submit one project
3
Applicants should use Schedule A of this project application to request expedited funding. FEMA may provide remaining 50%
of funds through a project amendment, which will require the Applicant to provide documentation to support expenditures of the
entire claimed cost, including the first 50%. Because expedited funding is awarded based on reduced documentation
requirements, FEMA will only fund these projects for specific time periods.
4
If the follow-up funding request is for the same activities and time periods, the original project application will be amended. If
the follow-up funding request is for distinguishable activities or time periods an additional project application may be submitted.
Last Updated: April 10, 2020 3
application for activities with environmental or historic preservation considerations and another
project application with their remaining activities. For additional information, see the COVID-19 Fact
Sheet: Environmental and Historic Preservation and Emergency Protective Measures for COVID-19.
The project application has four sections and six supplemental schedules. All Applicants must complete
sections I, II, III, and IV and one or more of the following schedules:
• Schedule A, B, C, or EZ depending on the cost and activity status.
• Schedule D when claiming costs equal to or greater than $131,100
5
for certain activities.
• Schedule F when claiming costs for activities that may have environmental and historic
preservation concerns.
Table 1 illustrates the circumstances under which each schedule should be completed.
Cost
Funding
Request Type
Work
Status
Schedules Required
A
B
C
D
EZ
F*
Less than
$131,100
Small Any Any
X
X
Equal to or
greater
than
$131,100
Large
Expedited
Any Applicant-Provided Information
X
X
Large
Regular
Complete Actual Costs
X
X
X
In-progress
X
X
X
Not started Applicant-Provided Information
X
X
X
*Schedule F may be required based on specific activities.
What happens after submitting the project application?
FEMA and the Recipient will review the information in the project application and may follow up with
limited requests for additional information as part of the process outlined in the FEMA Fact Sheet
Coronavirus (COVID-19) Pandemic: Public Assistance Simplified Application. After submission:
1. FEMA and the Recipient review the project application and validate information and documentation
provided to ensure compliance with all federal laws and regulations. If there are additional
questions to evaluate the eligibility of the project application, FEMA and the Recipient will contact
the Applicant to discuss. This may include contacting the Applicant by phone or through the Public
Assistance Grants Portal.
2. Upon completion of these reviews, the Applicant will be notified that funding for their project
application is ready to be awarded. The Applicant will be required to review, agree to terms and
conditions, and sign to accept the subaward in the Public Assistance Grants Portal.
3. Once the Applicant signs the subaward, FEMA makes funding available to the Recipient for
disbursement to the Applicant.
4. Once FEMA obligates and transfers funding for the subaward, the Applicant will become a
Subrecipient in the Public Assistance program. The Recipient may request additional information
before disbursing funds to the Subrecipient.
5. The Recipient will work directly with the Subrecipient to: monitor and report on the status of the
activities, comply with federal and Recipient grant requirements, and close the subaward in
accordance with 44 C.F.R. § 206.204-209, 2 C.F.R. Part 200, FEMA’s Public Assistance Program
and Policy Guid (PAPPG), and FEMA’s Program Management and Grant Closeout SOP.
5
FEMA establishes a threshold to categorize projects as large or small based on the final approved amount of eligible costs
after any cost adjustments, including insurance deductions. The threshold is adjusted for each federal fiscal year. For more
details, see https://www.fema.gov/public-assistance-indicator-and-project-thresholds.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 4
Section I – Project Application Information
Instructions: Applicants must complete this section and should refer to the Public Assistance Grants Portal for the declaration #
and FEMA PA code. The Applicant must assign a unique title and number for
each project application. This title and number can
help the Applicant connect
this project application to their accounting or other systems. Any documents attached to this project
application should include the project application number and title.
Declaration #:
Name of Organization Applying:
FEMA PA Code:
Applicant-Assigned Project
Application #:
Project Application Title:
Continue to Section II – Scope of Work.
Section II – Scope of Work
Instructions:
Applicants must complete this section and describe the activities that the Applicant conducted or will conduct in
response to COVID-19. For certain activities Applicants must provide additional information in Schedules D and F.
1. DESCRIPTION OF ACTIVITIES
Please provide a brief description of the activities the Applicant conducted or will conduct
:
Please select all the activities the Applicant conducted or will conduct
:
Management, control, and reduction of immediate threats to public health and safety
☐ Emergency operations center activities
☐ Training
☐ Facility disinfection
☐ Technical assistance on emergency management
☐ Dissemination of information to the public to provide warnings and guidance
☐ Pre-positioning or movement of supplies, equipment, or other resources
☐ Purchase and distribution of food, water, or ice
☐ Purchase and distribution of other commodities
☐ Security, law enforcement, barricading, and patrolling
☐ Storage of human remains or mass mortuary services
☐ Other. Please describe:
Emergency Medical Care
☐ Purchase and distribution/use of medical supplies & equipment including:
In vitro diagnostic supplies
☐ Personal protective equipment including:
☐ Respirators
☐ N95 Respirators
☐ Medical gloves
☐ Surgical masks
☐ Medical gowns
☐ Coveralls
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 5
☐
Face shields
☐ Other Personal Protective Equipment (PPE). Please describe:
☐ Decontamination systems
☐ Ventilators and products modified for use as ventilators
☐ Therapeutics
☐ Other. Please describe:
☐ Provision of
medical services
including:
☐ Disease testing
☐ Treatment
☐ Diagnosis
☐ Emergency medical transport
☐ Medical waste disposal
☐ Other. Please describe:
☐ Enhanced
medical facilities
including:
☐ Alternate Care Sites or other temporary medical facilities
☐ Expansion of capacity within an existing medical facility
☐ Community-based testing sites
☐ Other. Please describe:
Sheltering
☐ Isolation-related temporary lodging
☐ Quarantine-related temporary lodging
☐ High-risk population sheltering
☐ Healthcare worker and first responder temporary lodging
☐ Household pet or assistance animal or service animal sheltering
☐ Other. Please describe:
Other
☐ Other activity. Please describe:
Complete Schedule F if any of the following activities are reported above: storage of human remains or mass mortuary
services, decontamination systems, or medical waste disposal.
Please select the method(s) of work the Applicant used or will use to complete the activities reported
above:
☐ Establishment of temporary facilities, including:
☐ Repurposing, renovating, or reusing existing facilities.
☐ Placing prefabricated facilities on a site.
☐ Constructing new temporary medical or sheltering facilities.
☐ Staging resources at an undeveloped site.
☐ Purchase of meals for emergency workers
☐ Purchase of supplies or equipment
☐ Purchase of land or buildings
Complete Schedule F if any of the following activities are reported above: establishment of temporary facilities or staging
resources at an undeveloped site.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 6
2. LOCATIONS
Please select the locations where the activities reported above were or will be conducted:
☐ Jurisdiction-wide
☐ Geographic area(s). Please attach a list of all areas.
☐
Specific sites. Please attach a list of all addresses or GPS coordinates.
Continue to Section III – Cost and Work Status Information.
Section III – Cost and Work Status Information
Instructions: Applicants must complete this section and provide the costs of the activities reported in Section II. Applicants
must also complete Schedule A, B, C, or EZ as instructed below to estimate a project cost.
1. GENERAL COST & WORK STATUS QUESTIONS
Optional: Request Expedited Funding
An Applicant may request approval for expedited funding from the Recipient and FEMA if they have an immediate need
for funding to continue life-saving emergency protective measures. If approved, the Applicant will be awarded 50% of the
FEMA-confirmed project cost based on initial documentation. However, the Applicant will then be required to provide
all
information
, including all documentation to support actual incurred costs, to support the initial 50% of funding before
receiving
any additional funding
. Applicants will be required to return any funds that were not spent in compliance with
the program’s terms and conditions. In general,
Applicants who have never received FEMA Public Assistance funding and
do not have significant experience with federal grant requirements should avoid expedited funding
or, at a minimum,
discuss expedited funding with their Recipient emergency management office prior to requesting expedited funding.
Expedited funding is only available for activities completed during specific time periods.
Does the Applicant want to request expedited funding?
☐ No. Continue to the next question.
☐
Yes. Please complete Schedule A to request an expedited project from FEMA and return to Section IV.
Is the Applicant’s estimated cost for activities reported in Section II greater than or equal to $131,100?
☐ Yes. Continue to the next question.
☐ No. Please complete Schedule EZ to provide a small project estimate and return to Section III Part 2.
What is the status of the activities reported in Section II?
An Applicant may not request funding for activities conducted prior to January 20, 2020, the beginning of the COVID-19
incident period. This question should be answered once to describe all the activities reported in Section II (i.e. the earliest
start date and the latest end date). If FEMA’s eligibility criteria for certain activities are limited to specific time periods,
FEMA will ask for the time period that a particular activity was or will be conducted.
☐ Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY).
Please complete Schedule B to provide actual cost documentation and return to Section III Part 2.
☐ Activities started ______ (MM/DD/YY), ___% complete, and projected to end ______ (MM/DD/YY).
Please complete Schedule C to provide a detailed cost estimate and return to Section III Part 2.
☐ Activities started ______ (MM/DD/YY), ___% complete, with no predictable end date.
Please complete Schedule C to provide a detailed cost estimate and return to Section III Part 2.
☐ Activities have not started.
Please complete Schedule C to provide a detailed cost estimate and return to Section III Part 2.
2. PROJECT COST
What is the total net cost?
Please enter the total net cost from Schedule B, C or EZ.
$
If the total net cost is greater than or equal to $131,100 and the Applicant is not requesting expedited
funding, please complete Schedule D and return to Section IV – Project Certifications.
If the total net cost is less than $131,100 or the Applicant is requesting expedited funding, please
continue to Section IV – Project Certifications.
4/30/20
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 7
Section IV – Project Certifications
Instructions: Applicants must complete this section to certify that the activities and costs reported in this project application
comply with applicable federal, state, tribal, territorial, and local laws and regulations.
1. CERTIFICATION THAT BENEFITS WILL NOT BE DUPLICATED
Has the Applicant applied for any funding for COVID-19 from any other federal program?
An Applicant may request funding from other programs but may not receive funding for the same costs from multiple
programs.
☐ No.
☐ Yes. Please list other programs:
If yes,
has the Applicant applied for any funding from any other federal program for the activities reported
in Section II?
☐ No.
☐ Yes, but the other federal program has not yet approved the funding. The Applicant must inform FEMA if
funding is approved and either (a) withdraw the FEMA project application for any non-obligated subaward or (b) request to
close the subaward and return withdrawn funding for any obligated subaward.
☐ Yes, but the other federal program has conclusively denied the funding. Please attach denial.
I certify that the specific activities and costs in this project application were not requested from another
funding source or, if they were requested, that other source has not yet approved the funding. Further, I
certify that if the Applicant does receive funding for the specific activities and costs in this project
application, I must notify the Recipient and FEMA, and funding will be reconciled to eliminate duplication.
Applicant Authorized Representative
Title
Signature
2. GENERAL CERTIFICATION
I certify the following:
Activity Certifications
As required by Title 44 Code of Federal Regulations (C.F.R.) §§ 206.223 and 206.225 and in accordance
with the Public Assistance Program and Policy Guide (PAPPG), the Emergency Protective Measures
described in this project were or are:
• The Applicant’s legal responsibility;
• Undertaken in response to the COVID-19 threat caused by the declared event; and
• Undertaken because they were necessary to eliminate threats to life, public health, and safety.
Any activity claimed has to have been performed or is being performed at the direction of or pursuant to
guidance of state, local, tribal, or territorial public health officials (such as an executive order or other official
order signed by a public health official).
If any activity was or will be occurring on private property: For each property, the Applicant (A) had or has a legal
basis and authority to conduct the activities; and (B) completed or will complete the following actions for each
property for which supporting documentation will be maintained: (i) obtained a right-of-entry, (ii) signed an
agreement with the property owner to indemnify and hold harmless the Federal Government, and (iii) made efforts
to identify any known insurance proceeds for the same activities.
Cost Certifications
As required by 44 C.F.R. § 206.228 and 2 C.F.R. Part 200 and in accordance with the PAPPG, the costs for
which the Applicant is claiming reimbursement were or are:
• Of a type generally recognized as ordinary and necessary for the type of facility or activities;
• Reduced by applicable credits, such as insurance proceeds and salvage values; and
• Reasonable as demonstrated by the method selected in Schedule A, B, C or EZ of this project application.
As required by the Stafford Act § 312, 42 U.S. Code § 5155, and 2 C.F.R. §200.406 and in accordance
with the PAPPG, the Applicant has either:
• Informed FEMA of all insurance proceeds; or
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 8
• Did not have insurance coverage in place for the claimed costs at the time of the declaration.
If claiming contract costs: The Applicant complied with federal, Recipient, and Applicant procurement
requirements.
If claiming equipment costs: The Applicant complied with all FEMA policies regarding equipment rates in
accordance with the PAPPG.
If claiming labor costs: The Applicant complied with all FEMA policies regarding labor in accordance with the
PAPPG.
Environmental and Historic Preservation Compliance Certifications
In accordance with the PAPPG, the Applicant will comply with applicable federal, state, and local laws; will
provide all documentation requested to allow FEMA to ensure project applications comply with federal
Environmental and Historic Preservation (EHP) laws, implementing regulations, and Executive Orders; and will
comply with any EHP compliance conditions placed on the grant.
Documentation Certifications
In accordance with 2 C.F.R. §200.333 as well as state and local record retention requirements, the
Applicant will maintain all documentation that supports this project application in its own files. This
documentation will be required if the Applicant submits an appeal for additional funding, as well as in the
case of any audits.
It is important to know that upon submittal your project application becomes a legal document. The
Recipient or FEMA may use external sources to verify the accuracy of the information you enter. It is a
violation of Federal law to intentionally makes false statements or hide information when applying for
Public Assistance. This can carry severe criminal and civil penalties including a fine of up to $250,000,
imprisonment, or both. (18 U.S.C. §§ 287, 1001, 1040, and 3571). I certify that all information I have
provided regarding the project application is true and correct to the best of my knowledge. I understand
that, if I intentionally make false statements or conceal any information in an attempt to obtain Public
Assistance, it is a violation of federal laws, which carry severe criminal and civil penalties.
Applicant Authorized Representative
Title
Signature
3. PREPARER CERTIFICATION
Did the Applicant Authorized Representative receive consultant support or technical assistance in
preparing this project application from anyone not directly employed by the Applicant?
☐ No.
☐ Yes. Please provide the following information and obtain the preparer’s certification.
Preparer’s Company or Firm Name
Preparer’s Company or Firm EIN
Preparer’s Company or Firm Address
By signing below, I certify all information provided in this project application is true and correct based on
all information of which I have any knowledge.
I understand that causing the Applicant to make false
certification or statements or conceal any information in an attempt to obtain disaster aid is a violation
of federal laws, which carry severe criminal and civil penalties, including a fine of up to $250,000,
imprisonment, or both (18 U.S.C. Part 287, 1001, 1040 and 3571).
Preparer’s Name
Preparer’s Title
Preparer’s Signature
Please ensure that you have completed all schedules applicable to the activities you performed.
You have completed the project application. Thank you.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 9
SCHEDULE A – Expedited Funding Estimate
Instructions: The Applicant must complete this section if requesting expedited funding in Section III of the project application.
Expedited funding is only available if the total net cost for the request is greater than or equal to $131,100.
1. GENERAL ELIGIBILITY
Please explain why there is an immediate need for funding:
Please select the time-period for which the Applicant is requesting expedited funding for the
activities
reported in Section II:
Because expedited funding is awarded based on reduced documentation requirements, FEMA funds these projects for
specific time periods.
Start Date: ____________
(MM/DD/YY)
Designated Time-Period:
☐ 30 days
☐ 60 days
☐ 90 days
☐ Another time-period:
__________
Please describe how the activities reported in Section II address an immediate threat to life, public
health, or safety:
If it is not clear that a direct threat to life, public health,
or safety exists, or that the activity is necessary to cope with the threat,
FEMA may request documentation to demonstrate that the Applicant conducted the activities at the direction or guidance of
public health officials. See PAPPG at pp. 19-20, 42-43, and 57.
Please select the reason why the activities reported in Section II are the legal responsibility of the
Applicant
:
☐ The Applicant is a government organization and the state’s, tribe’s, or territory’s constitution or laws
delegate jurisdictional powers to the Applicant.
☐ A statute, order, contract, articles of incorporation, charter, or other legal document makes the
Applicant responsible to conduct the activities for the general public. Please describe:
☐ For other reasons. Please describe:
To determine legal responsibility for Emergency Protective Measures, FEMA evaluates whether
the Applicant requesting the
assistance either had jurisdiction over the area in which work was performed or the legal authority to conduct the activities. In
general, an Applicant only has legal responsibility to conduct Emergency Protective Measures within its jurisdiction. If an
Applicant conducts Emergency Protective Measures outside its jurisdiction, it must demonstrate its legal basis and
responsibility to conduct those activities. See PAPPG at pp. 20-21 and 41-42.
2. PROJECT COST & COST ELIGIBILITY
Please select the resources necessary to complete the activities reported in Section II. For each resource
selected, please provide the cost or other information FEMA can use to estimate the cost.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 10
☐
Contracts.
Cost
$
Please enter the total cost of contracts and provide copies of the request for proposals, bid documents or signed contracts.
If contracts are not available, please provide a unit price estimate and the basis for the unit prices (for example, historic
price documentation, or vendor quotes).
FEMA provides funding for contract costs based on the terms of the contract if the Applicant meets federal procurement
and contracting requirements. See PAPPG at pp. 30-33. The federal procurement under grant rules are found at
2 C.F.R. §§ 200.317-200.326
. Different sets of procurement rules apply depending on whether you are a state or a non-
state entity. For additional information see FEMA’s Procurement Under Grants Public Assistance Policy and FEMA Fact
Sheet: Procurement Under Grants: Under Exigent or Emergency Circumstances.
☐
Labor.
Including the Applicant’s own staff, Mutual Aid, prison labor, or National Guard.
Cost
$
Please enter the total cost of labor and provide a copy of the calculation. If not available, please provide the following
(attach a list if necessary):
• Number of personnel:
• Average hours per day:
• Average days per week:
• Average pay rate:
If the personnel were or will be provided through mutual aid, please provide the written mutual aid agreement.
FEMA reimburses force account labor costs based on actual hourly rates plus the cost of the employee’s actual fringe
benefits. FEMA determines the eligibility of overtime, premium pay, and compensatory time costs based on the Applicant’s
pre-disaster written labor policy. For Emergency Work activities conducted by budgeted employees, FEMA will only
reimburse overtime salary costs. See PAPPG at pp. 23-26 and 33-35.
☐
Equipment.
Including applicant owned, purchased, or rented.
Cost
$
Please enter the total cost of equipment. If Applicant’s own equipment, provide the following (attach a list if necessary):
• Number and types of equipment used:
• Average hours used per day:
• Average days per week:
• Average hourly rate:
If purchased, enter the purchase price.
If rented, provide the rental agreement and enter the rental price.
FEMA provides funding for the use of Applicant-owned equipment based on hourly rates. If an Applicant does not have
sufficient equipment to effectively respond to an incident, FEMA may provide funding for purchased or leased equipment.
Costs are eligible if the Applicant performed an analysis of the cost of leasing versus purchasing the equipment. FEMA
funds the least costly option. See PAPPG at pp. 26-28.
☐
Materials and Supplies
.
Cost
$
Please enter the total cost of materials and supplies and provide the following (attach a list if necessary):
• Amount of materials and supplies, by type:
• Purchase or stock replenishment cost:
The cost of materials and supplies is eligible if (1) the materials or supplies were purchased and justifiably needed to
effectively address threats caused by COVID-19 or (2) the materials or supplies were taken from an Applicant's stock and
used to address threats caused by COVID-19. The Applicant needs to track items taken from stock with inventory
withdrawal and usage records. FEMA will also consider escalation of costs (such as due to shortages) or exigent
circumstances in evaluating cost reasonableness. See PAPPG at p. 22 and p. 28.
☐
Other costs.
Including travel costs, utilities and any other expenses not listed above.
Cost
$
Please enter the total cost and provide high-level information which can substantiate costs:
Other costs may include travel costs, utilities and other expenses directly tied to the performance of eligible work. Not all
costs incurred as a result of the incident are eligible. See PAPPG at pp. 21-22, and 41-42.
Subtotal Please add together costs of labor, equipment, materials and other costs.
$
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 11
3. DEDUCTIONS
Please select the credits available to offset costs of activities reported in Section II. For each selected,
please provide the deduction or other information FEMA can use to estimate the deduction.
☐
Insurance Proceeds.
This does
not
include payment from patient insurance; for that, continue to medical payments below.
Deduction
$
Does the Applicant have insurance coverage that might cover any activities reported in Section II?
☐ No.
☐ Yes, the Applicant anticipates receiving a payment from its insurance carrier.
☐ Yes, the Applicants has actually received a payment from its insurance carrier.
If yes, please enter the total amount of insurance proceeds and provide copy of insurance documentation.
FEMA cannot provide funding that duplicates insurance proceeds. FEMA requires the Applicant to take reasonable efforts to
pursue claims to recover insurance proceeds that the Applicant is entitled to receive from its insurer(s). See FEMA’s
Public
Assistance Policy on Insurance.
☐
Disposition.
Deduction
$
Please enter the total salvage value of purchased equipment and supplies (if greater than $5,000).
When purchased equipment, supplies, or materials are no longer needed for federally funded projects, FEMA reduces
eligible funding by the fair market value of each piece of equipment valued at $5,000 or more and unused residual
supplies and materials that total $5,000 or more. If the Applicant acquires or improves real property with funds, disposition
and reporting requirements apply. See PAPPG at pp. 29-30.
☐
Medical Payments.
Deduction
$
Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a
pre-existing private payment agreement.
FEMA can
not provide funding for emergency medical care costs if they are covered by another source, including private
insurance, Medicare, Medicaid, or a pre-existing private payment agreement. See PAPPG at pp. 63-64 and FEMA Fact
Sheet: Coronavirus (COVID-19) Pandemic: Emergency Medical Care
.
It is extremely important that Private Non-Profit and
government medical care providers, as well as any other Applicant completing Emergency Medical Care activities, take
caution to capture and document these cost deductions. If clear documentation is not available to show how medical
payments are deducted and not duplicated, the Applicant may not receive funding for otherwise eligible activities.
☐
Other Deductions.
Deduction
$
Please enter the total amount of other goods and services provided to for-profit entities or any other proceeds or payments
received or expected.
NET TOTAL
Please subtract all proceed deduction
s from the subtotal.
$
You have completed this schedule. Return to Section IV to certify and sign this project application.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 12
SCHEDULE B – Completed Work Estimate
Instructions: Applicants must complete this schedule if the Applicant (1) has completed the activities reported in Section II, (2)
has documentation available to support the actual costs, and (3) the cost of the activities is over $131,100.
1. PROJECT COST & COST ELIGIBILITY
Please select the resources necessary to complete the activities reported in Section II. For each resource
selected, please provide the cost and requested information.
☐
Contracts.
Cost
$
Please enter the total cost of contracts. To calculate the total cost, complete FEMA Public Assistance COVID-19 Contracts
Report (attached) or provide all information contained therein.
Please also provide:
☐
Contracts, change orders, and summary of invoices
☐
Cost or price analysis (for contracts above $250,000, the federal simplified acquisition threshold)
☐
The Applicant’s procurement policy
☐
Other procurement documents that support the that the cost was reasonable (for example, requests for proposals,
bids, selection process, or justification for non-competitive procurement)
☐
Documentation that substantiates a high degree of contractor oversight, such as daily or weekly logs, records of
performance meetings (required for time and materials contracts)
FEMA provides funding for contract costs based on the terms of the contract if the Applicant meets federal procurement
and contracting requirements. See PAPPG at pp. 30-33. The federal procurement under grant rules are found at
2 C.F.R. §§ 200.317-200.326
. Different sets of procurement rules apply depending on whether the Applicant is a state or a
non-state entity. For additional information see FEMA’s Procurement Under Grants Public Assistance Policy and FEMA Fact
Sheet: Procurement Under Grants: Under Exigent or Emergency Circumstances.
☐
Labor.
Including the Applicant’s own staff, mutual aid, prison labor, and
National Guard.
Cost
$
Please enter the total cost of labor. To calculate the total cost, complete FEMA Form 009-0-123 Force Account Labor
Summary and FEMA Form 009-0-128 Applicants Benefit Calculation Worksheet or provide all information contained therein.
Please also provide:
☐
Justification for any standby time claimed
☐
Labor pay policy (must cover each employee type used, for example part time, full time, and temporary)
☐
National Guard pay policy (required for National Guard)
☐
Mutual aid agreement (required for mutual aid labor)
☐
Timesheets (please provide either (1) a summary list of all your timesheets, which FEMA will sample and request
copies of a limited number of time sheets; or (2) a sample set of timesheets and a detailed explanation of the
sampling methodology you used to select the representative sample)
☐
Daily logs or activity reports (please provide either (1) a summary list of all your logs or reports, which FEMA will
sample and request copies of a limited number of logs or reports; or (2) a sample set of logs or reports and a detailed
explanation of the sampling methodology you used to select the representative sample)
Please describe any labor that was not Applicant’s own staff, mutual aid, prison labor, or National Guard:
FEMA reimburses force account labor costs based on actual hourly rates plus the cost of the employee’s actual fringe
benefits. FEMA determines the eligibility of overtime, premium pay, and compensatory time costs based on the Applicant’s
pre-disaster written labor policy. For Emergency Work activities conducted by budgeted employees, FEMA will only
reimburse overtime salary costs. See PAPPG at pp. 23-26 and 33-35.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 13
☐
Equipment.
Including applicant owned, purchased, or rented.
Cost
$
Please enter the total cost of equipment. To calculate the total cost, complete FEMA Form 009-0-127 Force Account
Equipment Summary and FEMA Form 009-0-125 Rented Equipment Summary Record or provide all information contained
therein. Please also answer the following questions:
How did the Applicant acquire the equipment?
☐ Owned prior to January 20, 2020.
☐ Purchased. Please provide invoices or receipts, and a rental vs. purchase cost comparison.
☐ Rented. Please provide rental agreement, invoices or receipts, and a rental vs. purchase cost comparison.
What was the basis of the rate used in the summary?
Please select all that apply.
☐ FEMA Equipment Rates.
☐ Applicant’s Equipment Rates. Note, If the Applicant is not a state- or territory-level entity, they typically must
use the lesser of their own rate or FEMA’s rate.
☐ No rate is available, and the Applicant would like FEMA to calculate an Equipment Rate. For all
equipment where a rate is requested, please provide the original purchase price and documentation, the year
purchased, and the total useful lifetime hours.
☐ Other. Please describe:
If purchase or rental was over $250,000, the federal simplified acquisition threshold, please also provide all information
requested of contracts above.
FEMA provides funding for the use of Applicant-owned equipment based on hourly rates. If an Applicant does not have
sufficient equipment to effectively respond to an incident, FEMA may provide funding for purchased or leased equipment.
Costs are eligible if the Applicant performed an analysis of the cost of leasing versus purchasing the equipment. FEMA
funds the least costly option. See PAPPG at pp. 26-28.
☐ Materials and supplies.
Cost
$
Please enter the total cost of materials and supplies. To calculate the total cost, complete FEMA Form 009-0-124 Materials
Summary Record or provide all information contained therein.
How did the Applicant acquire the materials or supplies?
☐ From stock. Please provide cost documentation such as original invoices or other historical cost records,
inventory records, and—if available--supporting documentation such as daily logs.
☐ Purchased. Please provide invoices or receipts, and justification if purchased materials or supplies were not
used. If purchase was over $250,000, the federal simplified acquisition threshold, please also provide all information
requested of contracts above.
The cost of materials and supplies is eligible if (1) the materials or supplies were purchased and justifiably needed to
effectively address threats caused by COVID-19 or (2) the materials or supplies were taken from an Applicant's stock and
used to address threats caused by COVID-19. The Applicant needs to track items taken from stock with inventory withdrawal
and usage records. FEMA will also consider escalation of costs (such as due to shortages) or exigent circumstances in
evaluating cost reasonableness. See PAPPG at pp. 22 and 28.
☐ Other costs.
Including travel costs, utilities and any other expenses not listed above.
Cost
$
Please enter the total cost. Please also describe the costs:
Please a
lso provide invoices or receipts. If claiming travel expenses, please provide a travel policy.
Other costs may include travel costs, utilities and other expenses directly tied to the performance of eligible work. Not all
costs incurred as a result of the incident are eligible. See PAPPG at pp. 21-22, and 41-42.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 14
Subtotal Please add together costs of labor, equipment, materials and other costs.
$
2. DEDUCTIONS
Please select the credits available to offset costs of activities reported in Section II. For each selected,
please provide the deduction or other information FEMA can use to estimate the deduction.
☐
Insurance Proceeds.
This does
not
include payment from patient insurance; for that, continue to medical payments below.
Deduction
$
Does the Applicant have insurance coverage that might cover any activities reported in Section II?
☐ No.
☐ Yes, but the Applicant has not filed a claim yet.
☐ Yes, the Applicant anticipates receiving a payment from its insurance carrier.
☐ Yes, the Applicants has actually received a payment from its insurance carrier.
If yes, please enter the total amount of insurance proceeds and provide copy of insurance documentation.
FEMA cannot provide funding that duplicates insurance proceeds. FEMA requires the Applicant to take reasonable efforts to
pursue claims to recover insurance proceeds that the Applicant is entitled to receive from its insurer(s). See FEMA’s
Public
Assistance Policy on Insurance.
☐
Disposition.
Deduction
$
Please enter the total salvage value of purchased equipment and supplies (if greater than $5,000) and answer additional
questions in Schedule D.
When purchased equipment, supplies, or materials are no longer needed for federally funded projects, FEMA reduces
eligible funding by the fair market value of each piece of equipment valued at $5,000 or more and unused residual
supplies and materials that total $5,000 or more. If the Applicant acquires or improves real property with funds, disposition
and reporting requirements apply. See PAPPG at pp. 29-30.
☐
Medical Payments.
Deduction
$
Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a
pre-existing private payment agreement.
FEMA cannot provide funding for emergency medical care costs if they are covered by another source, including private
insurance, Medicare, Medicaid, or a pre-existing private payment agreement. See PAPPG at pp. 63-64 and FEMA Fact Sheet:
Coronavirus (COVID-19) Pandemic: Emergency Medical Care
.
It is extremely important that Private Non-Profit and government
medical care providers, as well as any other Applicant completing Emergency Medical Care activities, take caution to capture
and document these cost deductions. If clear documentation is not available to show how medical payments are deducted
and not duplicated, the Applicant may not receive funding for otherwise eligible activities.
☐
Other Deductions.
Deduction
$
Please enter the total amount of other goods and services provided to for-profit entities or any other proceeds or payments
received or expected.
NET TOTAL
Please subtract all proceed deductions from the subtotal
.
$
You have completed this schedule. Return to Section III.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 15
SCHEDULE C – In Progress Work Estimate
Instructions: Applicants must complete this schedule if the Applicant (1) has not started or is in the process of completing the
activities reported in Section II and (2) the cost of the activities reported in Section II is over $131,100.
1. BUDGET ESTIMATE
Please attach a budget estimate created using standard procedures the Applicant would use absent
federal funding.
The estimate should be broken down by the resource necessary to complete the work (contracts, labor, equipment, materials
& supplies, and other costs) and within those areas broken down further by the costs completed and future costs.
What is the basis for the Applicant’s cost estimate? (select all that apply)
☐ Extrapolation of completed costs.
☐ Historical unit costs.
☐ Average costs for similar work in the area.
☐ Published unit costs from national cost estimating database.
☐ Contractor or vendor quotes.
☐ Other. Please describe:
2. PROJECT COST & COST ELIGIBILITY
Please select the resources necessary to complete the activities reported in Section II. For each resource
selected, please provide the cost incurred to date and estimated future costs. Please also provide the
other requested information.
☐
Contracts.
Completed
Cost
$
+
Future
Cost
$
=
Total Cost
$
Please enter the completed cost of contracts. If no contracts-related costs are complete enter 0. To calculate the completed
cost, complete FEMA Public Assistance COVID-19 Contracts Report (attached) or provide all information contained therein.
For completed costs, please also provide:
☐
Contracts, change orders, and summary of invoices
☐
Cost or price analysis (for contracts above $250,000, the federal simplified acquisition threshold)
☐
The Applicant’s procurement policy
☐
Other procurement documents that support that the cost was reasonable (for example, requests for proposals, bids,
selection process, or justification for non-competitive procurement)
☐
Documentation that substantiates a high degree of contractor oversight, such as daily or weekly logs, records of
performance meetings (required for time and materials contracts)
Please enter the estimated future cost of contracts. To calculate the future cost, please use the procedures the Applicant
would normally use to create a budget estimate and answer the following questions:
Is the estimate based on awarded contracts?
☐ Yes. Please complete the FEMA Public Assistance COVID-19 Contracts Report (attached) and provide:
☐
Cost or price analysis (for contracts above $250,000, the federal simplified acquisition threshold)
☐
The Applicant’s procurement policy
☐
Other procurement documents that support the that the cost will be reasonable (for example, requests for
proposals, bids, selection process, or justification for non-competitive procurement)
☐ No. Please provide:
☐
Cost or price analysis (for projected contracts above $250,000, the federal simplified acquisition threshold)
☐
The Applicant’s procurement policy
Please add the completed to the future costs and enter result as the total cost.
FEMA provides funding for contract costs based on the terms of the contract if the Applicant meets federal procurement
and contracting requirements. See PAPPG at pp. 30-33. The federal procurement under grant rules are found at
2 C.F.R. §§ 200.317-200.326
. Different sets of procurement rules that apply depending on whether you are a state or a
non-state entity. For additional information see FEMA’s Procurement Under Grants Public Assistance Policy and FEMA Fact
Sheet: Procurement Under Grants: Under Exigent or Emergency Circumstances.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 16
☐
Labor.
Including the Applicant’s own staff, mutual aid, prison
labor, and National Guard.
Completed
Cost
$
+
Future
Cost
$
=
Total Cost
$
Please enter the completed cost of labor. If no labor-related costs are complete enter 0. To calculate the completed cost,
complete FEMA Form 009-0-123 Force Account Labor Summary and FEMA Form 009-0-128 Applicants Benefit Calculation
Worksheet or provide all information contained therein. Please also provide:
☐
Justification for any standby time claimed
☐
Labor pay policy (must cover each employee type used, for example part time, full time, and temporary)
☐
National Guard pay policy (required for National Guard)
☐
Mutual aid agreement (required for mutual aid labor)
☐
Timesheets (please provide either (1) a summary list of all your timesheets, which FEMA will sample and request
copies of a limited number of time sheets; or (2) a sample set of timesheets and a detailed explanation of the
sampling methodology you used to select the representative sample)
☐
Daily logs or activity reports (please provide either (1) a summary list of all your logs or reports, which FEMA will
sample and request copies of a limited number of logs or reports; or (2) a sample set of logs or reports and a detailed
explanation of the sampling methodology you used to select the representative sample)
Please describe any labor that was not Applicant’s own staff, mutual aid, prison labor, or National Guard:
Please enter the estimated future cost of labor. To calculate the future cost, please use the procedures the Applicant would
normally use to create a budget estimate and provide the following information:
☐
Labor pay policy (must cover each employee type used, for example part time, full time, and temporary)
☐
National Guard pay policy (required for National Guard)
☐
Mutual aid agreement (required for mutual aid labor)
Please add the completed costs to the future costs and enter result as the total cost.
FEMA reimburses force account labor costs based on actual hourly rates plus the cost of the employee’s actual fringe
benefits. FEMA determines the eligibility of overtime, premium pay, and compensatory time costs based on the Applicant’s
pre-disaster written labor policy. For Emergency Work activities conducted by budgeted employees, FEMA will only
reimburse overtime salary costs. See PAPPG at pp. 23-26 and 33-35.
☐
Equipment.
Including applicant owned, purchased, or rented.
Completed
Cost
$
+
Future
Cost
$
=
Total Cost
$
Please enter the completed cost of equipment. If no equipment-related costs are complete enter 0. To calculate the
completed cost, complete FEMA Form 009-0-127 Force Account Equipment Summary and FEMA Form 009-0-125 Rented
Equipment Summary Record or provide all information contained therein. Please also answer the following questions:
How did the Applicant acquire the equipment?
☐ Owned prior to January 20, 2020.
☐ Purchased. Please provide invoices or receipts, and a rental vs. purchase cost comparison.
☐ Rented. Please provide rental agreement, invoices or receipts, and a rental vs. purchase cost comparison.
What was the basis of the rate used in the summary?
Please select all that apply.
☐ FEMA Equipment Rates.
☐ Applicant’s Equipment Rates. Note, If the Applicant is not a State-level entity, they typically must use the
lesser of their own rate or FEMA’s rate.
☐ No rate is available, but the Applicant would like FEMA to calculate an Equipment Rate. For all
equipment where a rate is requested, please provide the original purchase price and
documentation, the year purchased, and the total useful lifetime hours.
☐ Other. Please describe:
If purchase or rental was over $250,000, the federal simplified acquisition threshold, please also provide all information
requested of contracts above.
Please enter the estimated future cost of equipment. To calculate the future cost, please use the procedures the Applicant
would normally use to create a budget estimate.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 17
Please add the completed to the future costs and enter result as the total cost.
FEMA provides funding for the use of Applicant-owned equipment based on hourly rates. If an Applicant does not have
sufficient equipment to effectively respond to an incident, FEMA may provide funding for purchased or leased equipment.
Costs are eligible if the Applicant performed an analysis of the cost of leasing versus purchasing the equipment. FEMA
funds the least costly option. See PAPPG at pp. 26-28.
☐
Materials and supplies.
Completed
Cost
$
+
Future
Cost
$
=
Total Cost
$
Please enter the completed cost of materials and supplies. If no materials- or supplies-related costs are complete enter 0. To
calculate the completed cost, complete FEMA Form 009-0-124 Materials Summary Record or provide all information
contained therein. Please also answer the following questions:
How did the Applicant acquire the materials or supplies?
☐ From stock. Please provide cost documentation such as original invoices or other historical cost record,
inventory records, and—if available—support documentation such as daily logs.
☐ Purchased. Please provide invoices or receipts, and justification if purchased materials or supplies were not
used. If purchase was over $250,000, the federal simplified acquisition threshold, please also provide all
information requested of contracts above.
Please enter the estimated future cost of materials and supplies. To calculate the future cost, please use the Applicants
standard procedures the Applicant would use to create a budget estimate and provide the following information:
Please add the completed costs to the future costs and enter result as the total cost.
The cost of materials and supplies is eligible if (1) the materials or supplies were purchased and justifiably needed to
effectively address threats caused by COVID-19 or (2) the materials or supplies were taken from an Applicant's stock and
used to address threats caused by COVID-19.
The Applicant needs to track items taken from stock with inventory
withdrawal and usage records. FEMA will also consider escalation of costs (such as due to shortages) or exigent
circumstances in evaluating cost reasonableness. See PAPPG at p. 22 and p. 28.
☐
Other costs.
Including travel costs, utilities and any other
expenses not listed above.
Completed
Cost
$
+
Future
Cost
$
=
Total Cost
$
Please enter the completed other costs. If no other costs are complete enter 0. To calculate the other costs, please use the
cost incurred and describe why it is reasonable:
Please also provide invoices or receipts. If claiming travel costs provide a travel policy.
Please enter the estimated future other costs. To calculate the future cost, please use the procedures the Applicant would
normally use to create a budget estimate.
Please add the completed costs to the future costs and enter result as the total cost.
Other costs may include travel costs, utilities and other expenses directly tied to the performance of eligible work. Not all
costs incurred as a result of the incident are eligible. See PAPPG at pp. 21-22, and 41-42.
Subtotal Please add together costs of labor, equipment, materials and other costs.
$
3. DEDUCTIONS
Please select the credits available to offset costs of activities reported in Section II. For each selected,
please provide the deduction.
☐
Insurance Proceeds.
This does
not
include payment from patient insurance; for that, continue to medical payments below.
Deduction
$
Does the Applicant have insurance coverage that might cover any activities reported in Section II?
☐ No.
☐ Yes, but has not filed a claim yet.
☐ Yes, the Applicant anticipates receiving a payment from its insurance carrier.
☐ Yes, the Applicants has actually received a payment from its insurance carrier.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 18
If yes, please enter the total amount of insurance proceeds and provide copy of insurance documentation.
FEMA cannot provide funding that duplicates insurance proceeds. FEMA requires the Applicant to take reasonable efforts to
pursue claims to recover insurance proceeds that the Applicant is entitled to receive from its insurer(s). See FEMA’s
Public
Assistance Policy on Insurance.
☐
Disposition.
Deduction
$
Please enter the total salvage value of purchased equipment and supplies (if greater than $5,000) and answer additional
questions in Schedule D.
When purchased equipment, supplies, or materials are no longer needed for federally funded projects, FEMA reduces
eligible funding by the fair market value of each piece of equipment valued at $5,000 or more and unused residual
supplies and materials that total $5,000 or more. If the Applicant acquires or improves real property with funds, disposition
and reporting requirements apply. See PAPPG at pp. 29-30.
☐
Medical Payments.
Deduction
$
Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a
pre-existing private payment agreement.
FEMA cannot provide funding for emergency medical care costs if they are covered by another source, including private
insurance, Medicare, Medicaid, or a pre-existing private payment agreement. See PAPPG at pp. 63-64 and FEMA Fact Sheet:
Coronavirus (COVID-19) Pandemic: Emergency Medical Care
.
It is extremely important that Private Non-Profit and government
medical care providers, as well as any other Applicant completing Emergency Medical Care activities, take caution to capture
and document these cost deductions. If clear documentation is not available to show how medical payments are deducted
and not duplicated, the Applicant may not receive funding for otherwise eligible activities.
☐
Other Deductions.
Deduction
$
Please enter the total amount of other goods and services provided to for-profit entities or any other proceeds or payments
received or expected.
NET TOTAL
Please subtract all proceed deductions from the subtotal.
$
You have completed this schedule. Return to Section III.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 19
SCHEDULE D – Large Project Eligibility Questions
Instructions: Applicants must complete part 1 of this schedule if the total net cost reported in Section III is greater than or equal
to $131,100. Additionally, if any of the following activities were reported in Section II, Applicants must answer the
corresponding question:
•
Purchase of supplies or equipment–Complete part 2.
•
Purchase of land or buildings–Complete part 3.
•
Purchase and distribution of food, water, ice, or other
commodities–Complete part 4
•
Purchase of meals for emergency workers–Complete part 5.
•
Pre-positioning or movement of supplies, equipment,
or other resources–Complete part 6.
•
Emergency medical care–Complete part 7 and 8.
•
Sheltering–Complete part 9.
•
Establishing a temporary facility–Complete part 10.
1. GENERAL ELIGIBILITY
Are all activities reported in Section II only being performed by the Applicant as a result of COVID-19?
☐ Yes.
☐ No. Please explain:
FEMA can only provide funding for costs that are a result of COVID-19 and above and beyond what the Applicant usually
incurs during its normal course of business. See PAPPG at pp. 21-22, and 41-42.
Is the Applicant legally responsible for performing the activities reported in Section II?
☐ Yes, the Applicant is a government organization and the state’s, tribe’s, or territory’s constitution or
laws delegate jurisdictional powers to the Applicant.
☐ Yes, a statute, order, contract, articles of incorporation, charter, or other legal document makes the
responsible to conduct the activities for the general public. Please attach and describe:
☐ Yes, for other reasons. Please attach supporting documentation and describe:
☐ No. Please describe how the Applicant is eligible for funding:
To determine legal responsibility for Emergency Protective Measures, FEMA evaluates whether the Applicant requesting the
assistance either had jurisdiction over the area in which work was performed or the legal authority to conduct the activities
. In
general, an Applicant only has legal responsibility to conduct Emergency Protective Measures within its jurisdiction. If an
Applicant conducts Emergency Protective Measures outside its jurisdiction, it must demonstrate its legal basis and
responsibility to conduct those activities. See PAPPG at pp. 20-21, and 41-42.
Please describe how the activities reported in Section II address an immediate threat to life, public
health, or safety:
If it is not clear that a direct threat to life, public health or safety
exists, or that the activity is necessary to cope with the threat,
FEMA may request documentation to demonstrate that the Applicant conducted the activities at the direction or guidance of
public health officials.
Did or will any of the activities reported in Section II require access to residential private property?
Leasing a private facility is not considered accessing a residential private property.
☐ No.
☐ Yes. Please identify and describe the activities taking place on private property:
FEMA may request additional information to demonstrate the Applicant’s legal authority and responsibility to enter private
property, the basis for the determination that a threat exists to the general public in that community, and copies of the rights-
of-entry and agreements to indemnify and hold harmless the Federal Government.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 20
For activities that involve the creation of a new program, please describe or attach the internal control
plan the Applicant executed or will execute to ensure costs incurred remain reasonable in accordance
with 2 C.F.R. Part 200, the FEMA Public Assistance Program and Policy Guide, and applicable Recipient
and Applicant requirements:
2. PURCHASE OF SUPPLIES OR EQUIPMENT
Please provide approximate quantities and unit costs for each type of supply or equipment reported in
Section II:
Supply or Equipment
Quantity
Unit Cost
In vitro diagnostic supplies
$
Respirators
$
N95 Respirators
$
Medical gloves
$
Surgical masks
$
Medical gowns
$
Coveralls
$
Face shields
$
Other Personal Protective Equipment (PPE).
$
Decontamination systems
$
Ventilators and products modified for use as ventilators
$
Therapeutics
$
Other
$
Did or will the Applicant purchase equipment or supplies with a total cost of greater than $5,000?
☐ No. Please skip the remaining questions in this part.
☐ Yes.
Please proceed to the next question.
If yes to the previous question, is the aggregate value or will the aggregate value of unused supplies be
greater than $5,000 after use for federal projects concludes?
☐ Unsure. Please skip the remaining question in this part. Please ensure you keep accurate records of unused supplies
as the Recipient or FEMA may request this information during an audit or when closing the Applicant’s subaward(s).
☐ No. Please skip the remaining questions in this part.
☐ Yes.
Please ensure the Applicant included disposition proceeds in Schedule B or C as applicable.
If the aggregate total of unused supplies is less than $5,000, FEMA does not reduce funding. See PAPPG at pp. 29-30.
(Tribal, local, and non-profit entities only) Does the Applicant anticipate any piece of equipment they
purchased will have fair market value of greater than $5,000 after its use for federal projects concludes?
☐ No.
☐ Yes
.
Please ensure the Applicant included disposition proceeds in Schedule B or C as applicable.
(State- and Territory Applicants only) Did the Applicant dispose of equipment in accordance with state or
territorial laws and procedures?
☐ No.
☐ Yes. Please ensure the Applicant included disposition proceeds in Schedule B or C as applicable.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 21
Did or will the Applicant distribute supplies or equipment to for-profit entities?
☐ No.
☐ Yes. Please describe how the Applicant will seek reimbursement for the fair market value of the supplies or equipment:
In certain cases, FEMA requires that funding be reduced by the remaining value of supplies and equipment after they are
no longer needed for federally funded projects. When equipment or supplies (including materials) purchased with PA
funding are no longer needed for response to or recovery from the incident, the Applicant may use the items for other
federally funded programs or projects, provided the Applicant informs FEMA. For more information on these requirements,
see PAPPG at pp. 29-30.
3. PURCHASE OF LAND OR BUILDINGS
Did or will the Applicant acquire or improve any real property?
FEMA defines real property as “Land, including land improvements, structures, and appurtenances thereto.” Real property
acquired with FEMA funds is subject to specific disposition and reporting requirements.
☐ No.
☐ Yes. The Applicant must obtain specific disposition instructions from FEMA. The Applicant should work through their
Recipient to obtain specific instructions when the acquired or improved property is no longer needed for the original
authorized purpose.
4. PURCHASE AND DISTRIBUTION OF FOOD, WATER, ICE, OR OTHER COMMODITIES
When did or will purchase and distribution of food, water, ice or other commodities start and end?
Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY).
Please attach any written requests and approvals for the activity given by the FEMA Regional Administrator or Recipient.
Please select and describe the work necessary to purchase and distribute food, water, ice or other
commodities:
☐ Purchasing and packaging. Please describe:
☐ Acquiring distribution and storage space. Please describe:
☐ Delivery and distribution. Please describe:
☐ Other. Please describe:
Did or will the Applicant distribute food, water, ice or other commodities to for-profit entities?
☐ No.
☐ Yes. Please describe how the Applicant will seek reimbursement for the fair market value of the food, water, ice or
other commodity:
Did or will the Applicant enter into a formal agreement or contract for the provision of food, water, ice or
other commodities through a private organization?
☐ No.
☐ Yes. Please ensure contract costs are captured and associated questions answered in Schedule B or C as applicable.
If the purchase and distribution involved food, how is food security negatively impacted, making food
distribution necessary to protect public health and safety?
Please select all that apply.
☐ Reduced mobility of those in need due to government-imposed restrictions.
☐ Marked increase or atypical demand for feeding resources.
☐ Disruptions to the typical food supply chain within the relevant jurisdiction.
☐ Other. Please describe:
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 22
5. PURCHASE OF MEALS FOR EMERGENCY WORKERS
Why are meals for emergency workers being claimed?
Please select all that apply.
☐ A labor policy or written agreement requires the provision of meals. Please attach.
☐ Conditions constituted a level of severity that requires employees to work abnormal, extended work
hours without a reasonable amount of time to provide for their own meals. Please describe:
☐ Food or water was or is not reasonably available for employees to purchase. Please describe:
☐ Other. Please describe:
Please check here to confirm that meals were provided I accordance with the following FEMA policy.
☐No meals claimed for reimbursement were provided:
• To individuals receiving a per diem
• At a restaurant
• For individual meals
For more information on these requirements, see PAPPG at p. 63.
6. PRE-POSITIONING OR MOVEMENT OF SUPPLIES, EQUIPMENT, OR OTHER RESOURCES
Please describe the resources the Applicant pre-positioned or will pre-position:
Please describe the activities that were or will be conducted
using the pre-positioned resources:
For more information on these requirements, see PAPPG at p. 60.
7. EMERGENCY MEDICAL CARE – GENERAL ELIGIBILITY
Please describe how the emergency medical care activities in Section II directly relate to the COVID-19:
Did or will the Applicant contract for the provision of emergency medical care?
☐ No, the Applicant directly provided the care.
☐ Yes. Please ensure contract costs are captured and associated questions answered in Schedule B or C as applicable.
Were the medical supplies & equipment, services, or facilities provided to or used by for-profit entities?
☐ No.
☐ Yes. Please describe how the Applicant will seek reimbursement for the fair market value of the emergency medical
care:
Please describe how the Applicant has, and will continue to pursue payment from patients’ private
insurance, Medicaid, Medicare, or any other source of funding:
It is extremely important that Private Non-Profit and government medical care providers, as well as any other Applicant
completing Emergency Medical Care activities, take caution to capture and document these cost deductions in Schedule B
or C. If clear documentation is not available to show how medical payments are deducted and not duplicated, the Applicant
may not receive funding for otherwise eligible activities.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 23
8. EMERGENCY MEDICAL CARE – MEDICAL SERVICES
If the Applicant is claiming anything other than set-up costs for alternate care sites, other temporary
medical facilities, or expansion of capacity within an existing medical facility, please provide additional
information about the emergency medical care activities.
When did or will the medical service activities start and end?
Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY).
Please attach any written requests and approvals for the activity given by the FEMA Regional Administrator or Recipient.
Please describe how the emergency medical delivery system within a declared area was or is destroyed,
severely compromised, or overwhelmed:
When the emergency medical delivery system within a declared area is destroyed, severely compromised, or overwhelmed,
FEMA may fund extraordinary costs associated with providing temporary facilities for emergency medical care or expanding
existing medical care capacity in response to the declared incident. Temporary facilities and expansions may be used to treat
COVID-19 patients or non-COVID-19 patients, as appropriate. For COVID-19 declarations where temporary facilities and
expansions require additional health care workers, state, tribal, territorial, and local governments may contract with medical
providers to provide medical services in these facilities. FEMA may provide assistance and approve funding for an initial 30
days, from the date that the facility is operational, as an immediate need notwithstanding that the services may be covered by
another source. If additional time is needed, the Applicant should request FEMA re-assess before the end of the 30 days and
FEMA may grant another 30-day extension as warranted. FEMA cannot duplicate funding provided by another source and will
reconcile final funding based on any funding provided by another agency or covered by insurance. Applicable requirements for
labor and contracting under federal grants apply. For more information on these requirements, see fema.gov/coronavirus and
the PAPPG at pp. 63-64.
9. SHELTERING
When did or will the sheltering activities start and end?
Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY).
Please describe how the sheltering was or is directly related to COVID-19:
Please describe how sheltering was or is being conducted in accordance with standards and guidance
approved by public health officials including social distancing measures:
Was the sheltering conducted in a non-congregate environment?
Congregate sheltering is sheltering in facilities with large open spaces. Non-congregate sheltering is sheltering in which each
individual or household has living space that offers some level of privacy. For more information, see PAPPG at pp. 66-67.
☐ Yes.
Please proceed to the next question.
☐ No. Please skip the remaining questions in this part.
Did the Applicant receive prior approval for non-congregate sheltering from FEMA?
☐ Yes. Please attach your request, all supporting documentation, and a copy of the FEMA approval.
☐ No. This activity requires the FEMA approval. Please submit a request through the Recipient directly to the FEMA
Regional Administrator.
For more information on these requirements, see fema.gov/coronavirus.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 24
Are the non-congregate sheltering activities completed?
☐ No.
☐ Yes. The Applicant needs to provide sufficient documentation to establish eligibility, including the following information
:
• Specific need for each individual sheltered
• Length of stay for each individual sheltered
• Age of each individual sheltered
• If applicable, number of meals provided for each individual sheltered. Please also answer questions in part 4
related to the purchase and distribution of food, water, ice, or other commodities
• If applicable, number of individuals with access or functional needs sheltered
• If applicable, number of household pets sheltered
• If applicable, number of assistance and service animals sheltered
• If applicable, type of shelter provided for animals as stand-alone, co-located, co-habitational
• Description of services provided to sheltered individuals
For more information on these requirements, see PAPPG at p. 67 and FEMA Fact Sheet: Coronavirus (COVID-
19) Pandemic:
Non-Congregate Sheltering- FAQ.
10. ESTABLISHING A TEMPORARY FACILITY
Applicants must complete this part if the activities conducted or to be conducted include the set-up or operation of a
temporary facility. The Applicant must either submit a separate project application for each facility or submit the information
in this part for each facility. For more information on these requirements, see the FEMA Coronavirus (COVID-19) Pandemic:
Eligible Emergency Protective Measures Fact Sheet and the PAPPG at pp. 76-80.
What is the name of this temporary facility?
What dates were or will the temporary facility used?
Start date: ____________ (MM/DD/YY) End date:_____________(MM/DD/YY)
What services did or will this temporary facility provide?
☐ Emergency medical care
☐ Sheltering
☐ Other. Please describe:
Why was or is this temporary facility needed?
☐ Existing facilities were or are forecasted to become overloaded and cannot accommodate the need.
☐ Quarantine of COVID-19 affected individuals.
☐ Additional space needed to accommodate COVID-19 related response activities.
☐ Other. Please describe:
Please indicate how the Applicant did or will establish the temporary facility and attach
a cost analysis
justifying the selection.
Please select all that apply.
☐ Rent a facility. Please provide a lease agreement.
☐ Purchase a facility. Please provide documentation to support the purchase price.
☐ Construct a new facility.
☐
Modify/expand an existing facility.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 25
If purchasing or constructing a new facility, has the Applicant completed its use of this temporary
facility?
☐ No.
☐ Yes. If the Applicant purchased or constructed a temporary facility, it must return to FEMA the federal share of the
equity in the facility. The Applicant must report the equity to FEMA when the approved deadline has expired or when the
facility is no longer needed for the authorized purpose, whichever occurs first. For more information on this requirement,
see PAPPG at pp. 79-80. Please ensure disposition proceeds are captured and associated questions answered in
Schedule B or C as applicable.
Is or will the temporary facility be accessible to and usable by disabled persons, as required by the
Americans with Disabilities Act?
☐ Yes, the existing facility is in compliance with the Americans with Disabilities Act and no alterations
were or will be required to make the facility ADA-compliant.
☐ Yes, the Applicant has made or will make all required alterations to ensure that the facility is in
compliance with the Americans with Disabilities Act.
☐ No. Please describe why compliance is not applicable to this facility:
For additional information on Americans with Disabilities Act, see PAPPG at pp. 95-96.
You have completed this schedule. Return to Section II.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 26
Schedule EZ – Small Project Estimate
Instructions: Applicant
s must complete this schedule if the total project cost is less than $131,100 and provide the costs of the
activities reported in Section II.
1. BUDGET ESTIMATE
Please attach a budget estimate created using standard procedures the Applicant would use absent
federal funding.
The estimate should be broken down by the resources necessary to complete the work (contracts, labor,
equipment, materials & supplies, and other costs).
If the activities are complete, please attach the corresponding summary records:
☐ FEMA Public Assistance COVID-19 Contracts Report (attached)
☐ FEMA Form 009-0-123 Force Account Labor Summary
☐ FEMA Form 009-0-128 Applicants Benefit Calculation Worksheet
☐ FEMA Form 009-0-127 Force Account Equipment Summary
☐ FEMA Form 009-0-125 Rented Equipment Summary Record
☐ FEMA Form 009-0-124 Materials Summary Record
If the activities are not yet complete, what is the basis for the estimate? (select all that apply)
☐ Extrapolation of completed costs.
☐ Historical unit costs.
☐ Average costs for similar work in the area.
☐ Published unit costs from national cost estimating database.
☐ Contractor or vendor quotes.
☐ Other. Please describe:
2. PROJECT COST
Please select the resources necessary to complete the activities reported in Section II. For each resource
selected, please provide the cost.
☐
Contracts.
Cost
$
Please enter the total cost of contracts from your estimate.
FEMA provides funding for contract costs based on the terms of the contract if the Applicant meets federal procurement
and contracting requirements. See PAPPG at pp. 30-33. The federal procurement under grant rules are found at
2 C.F.R. §§ 200.317-200.326
. Different sets of procurement rules that apply depending on whether you are a state or a
non-state entity. For additional information see FEMA’s Procurement Under Grants Public Assistance Policy and FEMA Fact
Sheet: Procurement Under Grants: Under Exigent or Emergency Circumstances.
☐ Labor.
Including the Applicant’s own staff, Mutual Aid, prison labor, National Guard.
Cost
$
Please enter the total cost of labor from your estimate.
FEMA reimburses force account labor costs based on actual hourly rates plus the cost of the employee’s actual fringe
benefits. FEMA determines the eligibility of overtime, premium pay, and compensatory time costs based on the Applicant’s
pre-disaster written labor policy. For Emergency Work activities conducted by budgeted employees, FEMA will only
reimburse overtime salary costs. See PAPPG at pp. 23-26 and 33-35.
☐ Equipment.
Including applicant owned, purchased, or rented.
Cost
$
Please enter the total cost of equipment from your estimate.
FEMA provides funding for the use of Applicant-owned equipment based on hourly rates. If an Applicant does not have
sufficient equipment to effectively respond to an incident, FEMA may provide funding for purchased or leased equipment.
Costs are eligible if the Applicant performed an analysis of the cost of leasing versus purchasing the equipment. FEMA
funds the least costly option. See PAPPG at pp. 26-28.
☐
Materials and Supplies.
Cost
$
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 27
Please enter the total cost of materials and supplies from your estimate.
The cost of materials and supplies is eligible if (1) the materials or supplies were purchased and justifiably needed to
effectively address threats caused by COVID-19 or (2) the materials or supplies were taken from an Applicant's stock and
used to address threats caused by COVID-19. The Applicant needs to track items taken from stock with inventory
withdrawal and usage records. FEMA will also consider escalation of costs (such as due to shortages) or exigent
circumstances in evaluating cost reasonableness. See PAPPG at p. 22 and p. 28.
☐
Other costs.
Including travel costs, utilities and any other expenses not listed above.
Cost
$
Please enter any other costs from your estimate and describe:
Other costs may include travel costs, utilities and other expenses directly tied to the performance of eligible work. Not all
costs incurred as a result of the incident are eligible. See PAPPG at pp. 21-22.
Subtotal Please add together costs of labor, equipment, materials and other costs.
$
3. DEDUCTIONS
Please select the credits available to offset costs of activities reported in Section II. For each selected,
please provide the deduction.
☐
Insurance Proceeds.
This does
not
include payment from patient insurance; for that, continue to medical payments below.
Deduction
$
Does the Applicant have insurance coverage that might cover any activities reported in Section II?
☐ No.
☐ Yes, the Applicant anticipates receiving a payment from its insurance carrier.
☐ Yes, the Applicants has actually recei
ved a payment from its insurance carrier.
If yes, please enter the total amount of insurance proceeds and provid
e copy of insurance documentation.
FEMA cannot provide funding that duplicates insurance proceeds. FEMA requires the Applicant to take reasonable efforts to
pursue claims to recover insurance proceeds that the Applicant is entitled to receive from its insurer(s). See FEMA’s
Public
Assistance Policy on Insurance.
☐
Disposition.
Deduction
$
Please enter the total salvage value of purchased equipment and supplies (if greater than $5,000).
When purchased equipment, supplies, or materials are no longer needed for federally funded projects, FEMA reduces
eligible funding by th
e fair market value of each piece of equipment valued at $5,000 or more and unused residual
supplies and materials that total $5,000 or more. If the Applicant acquires or improves real property with funds, disposition
and reporting requirements apply. See PAPPG at pp. 29-30.
☐
Medical Payments.
Deduction
$
Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a
pre-existing private payment agreement.
FEMA cannot provide funding for emergency medical care costs if they are covered by another source, including private
insurance, Medicare, Medicaid, or a pre-existing private payment agreement. See PAPPG at pp. 63-64 and FEMA Fact
Sheet: Coronavirus (COVID-19) Pandemic: Emergency Medical Care
.
It is extremely important that Private Non-Profit and
government medical care providers, as well as any other Applicant completing Emergency Medical Care activities, take
caution to capture and document these cost deductions. If clear documentation is not available to show how medical
payments are deducted and not duplicated, the Applicant may not receive funding for otherwise eligible activities.
☐
Other Deductions.
Deduction
$
Please enter the total amount of other goods and services provided to for-profit entities or any other proceeds or payments
received or expected.
NET TOTAL Please subtract all proceed deductions from the subtotal.
$
You have completed this schedule. Return to Section III, Part 2.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 28
SCHEDULE F – Environmental and Historic Preservation Questions
Instructions: Applicants must complete this schedule if any of the following activities are reported in Section II:
•
Staging resources at an undeveloped site–Complete part 1.
•
Storage of human remains or mass mortuary services–
Complete part 2.
•
Medical waste disposal–Complete part 3.
•
Decontamination systems–Complete part 4.
•
Establishment of temporary facilities–Complete part 5.
For additional information on EHP requirements, see the Environmental and Historic Preservation (EHP) and Emergency
Protective Measures for COVID-19 Fact Sheet.
1. STAGING RESOURCES AT AN UNDEVELOPED SITE
Please describe the staging activities:
The description should include if an asphalt or concrete pad was built or if other ground disturbing occurred. If ground
disturbing occurred, provide a general description of the disturbance, the general area and depth of the ground
disturbing and the equipment used. Ground disturbing activities may also include site preparation and clearing.
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longitude:
2. STORAGE OF HUMAN REMAINS OR MASS MORTUARY SERVICES
Please describe activities related to the storage or treatment of human remains or mass mortuary
services:
Please select the locations where the activities reported above were or will be conducted:
☐ Jurisdiction-wide
☐ Geographic area(s). Please attach a list of all areas.
☐
Specific sites.
Please attach a list of all addresses or GPS coordinates.
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longitude:
3. MEDICAL WASTE DISPOSAL
What is the intended method of disposal?
☐ Using an existing licensed disposal site.
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longitude:
☐ Creating a new disposal site. Please select one of the following:
☐ Landfill
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longitude:
☐ Incinerator
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longitude:
4. DECONTAMINATION SYSTEMS
Please describe decontamination activities:
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longitude:
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 29
5. ESTABLISHMENT OF TEMPORARY FACILITIES
Please confirm the method(s) of work the Applicant used or will use in establishing a temporary facility:
☐ Repurposing, renovating, or reusing existing facilities.
☐ Placing prefabricated facilities on a site.
☐ Constructing new temporary medical or sheltering facilities.
Please describe the temporary facilities established:
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longi
tude:
Will the Applicant only repurpose or reuse an existing facility?
☐ Yes, and the temporary use is the same as the most recent use of the facility. Please skip the remaining
questions in this part.
☐ Yes, but the temporary use is not the same as the most recent use of the facility. Please describe the
temporary use and the most recent use of the facility:
Please sk
ip the remaining questions in this part.
☐ No, the temporary use required renovation, placing prefabricated facilities or new construction.
If not new construction, what year was the facility built?
Please provide year built and note whether the date is approximate or exact: ________ ☐ Approximate ☐ Exact
Please describe the work in detail
or attach plans or other documentation describing the work:
The description should include a description of the following: For existing buildings, interior and exterior modification
descriptions including quantities, dimensions, and material types; and utility upgrade descriptions. For construction of
new facilities, a description of site activities and new construction. For placement of prefabricated facilities on sites, a
description of the prefabricated facility and any site work to be carried out.
Will the activity occur entirely within an already-developed area?
Examples of developed areas include an existing parking lot, a lot previously developed for construction with existing utility
tie-ins, or an existing asphalt or concrete pad.
☐ Yes.
☐ No.
If no, will the activity require the construction of a concrete or asphalt pad?
☐ No.
☐ Yes.
If yes, will the pad be removed when the temporary facility is no longer needed?
☐ No.
☐ Yes. Please describe planned demolition activities:
Will any ground disturbing activities occur as part of construction?
Ground disturbing activities may include site clearing and preparation, laying utilities, or expanding of existing utilities.
☐ No.
☐ Yes. Please attach a site plan for the temporary facility, including GPS coordinates and dimensions (length, width,
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 30
and depth) of the ground disturbance.
If yes, will the ground disturbance occur outside of an existing footprint or previously disturbed Right-
of-Way?
☐ No.
☐ Yes.
If yes,
will rooted vegetation be removed or cleared?
☐ No.
☐ Yes. Provide the GPS coordinates (decimal degrees with five decimal places):
If yes, will trees be removed?
☐ No.
☐ Yes. Provide the GPS coordinates (decimal degrees with five decimal places):
Number of trees:
Diameter of trees (approximate): units:
Will the activities include the use of staging areas for equipment or materials?
☐ No.
☐
Yes.
Provide the GPS coordinates for each site (decimal degrees with five decimal places):
Latitude: Longitude:
What surface does each staging area have (paved, gravel, grass field, etc.)?
Will the activities include expansion of parking facilities?
☐ No.
☐ Yes.
Will the activities involve the disposal of any existing materials as part of site preparation or
construction?
☐ No.
☐ Yes.
If yes, what are the types of debris?
Please select all that apply.
☐ Vegetative
☐ Construction and demolition
☐ Hazardous Materials
☐ Large Appliances
☐ Electronics
☐ Other. Please describe:
How will debris be removed?
☐ Using a contractor. Please provide the name of the vendor:
☐ Using other non-contracted resources.
Will there be any temporary staging of debris?
☐ No.
☐ Yes. Please provide permits (if available) and the GPS coordinates (decimal degrees with five decimal places):
Latitude: Longitude:
If vegetative was selected above, will any vegetative debris be burned?
☐ No.
☐ Yes.
What is the method of ash disposal?
Please provide permits, if available.
☐ Disposing in a Landfill.
☐ Spreading.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 31
☐
Burying.
☐ Other. Please describe:
Will fill or borrow material be used for site preparation?
☐ No.
☐ Yes.
What is the quantity of fill?
Units: ☐ Cubic yards ☐ Tons ☐ Other:
If yes, what is the type of fill and borrow material?
☐ Soil
☐ Sand
☐ Gravel
☐ Rock
☐ Other material. Please describe:
If yes, what is the source of the fill and borrow material?
☐ Commercial, please provide name of vendor:
☐ Private
☐ Municipal
☐ Other location. Please describe:
Please provide the GPS coordinates (decimal degrees with five decimal places) of the fill and borro
w sources:
Latitude: Longitude:
Are there any large, undeveloped or undisturbed areas on, or near, the site?
Select yes if there are large tracts of forestland, farmland, grassland, or naturally preserved areas, etc.
☐ No.
☐ Yes. Please describe:
Are any of the following environmental issues associated with the site or facility?
Select all that apply.
☐ Conservation Area or Wildlife Refuge
☐ Non-Attainment Area (Clean Air Act)
☐ Underground storage tanks
☐ Old gas stations or other potential toxic substance generators like dry cleaning, laboratories,
landfills, dumps, industrial sites
☐ Brownfield or Superfund sites
☐ Fuel or oil spills
☐ Other. Please describe:
☐ None apply
☐ Unsure if any apply
Are there any of the following known hazardous materials at or adjacent to the site?
If any are selected,
please attach applicable permits, if available.
☐ Solvents (thinners, cleaners, varnishes, and adhesives)
☐ Oil/Fuel/Hydraulics
☐ Chemical, pesticide or fuel storage tanks (above or below ground)
☐ Lead based paints, solder, flashing
☐ Pesticides
☐ Mercury containing waste (mercury switches, fluorescent bulbs, thermostats, etc.)
☐ PCB containing materials (transformers, caulking, etc.)
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 32
☐
Hazardous Medical Waste
☐ Asbestos containing products (sealants, insulation, tile, etc.)
☐ No.
☐ Unsure
Will any of the activities described in Section II be performed on any of the following?
Select all that apply.
☐ A facility listed in or eligible for listing in a local, state, or national register.
Please describe:
☐ A site in or adjacent to a historic district. Please describe:
☐ A locally recognized landmark. Please describe:
☐ A National Historic Landmark. Please describe:
☐ No.
☐ Unsure
If the Applicant selected any of the facility types listed above, and/or the facility is more than 45 years
old: Will the Applicant be requiring int
erior installations or exterior modifications?
☐ No.
☐ Unsure
☐ Yes. Please describe:
Please provide the following documentation, if available, to aid FEMA’s review of temporary facility
activities.
Check each box if the referenced documentation is provided.
☐ Permits and correspondence with regulatory agencies, if applicable.
☐ Site map showing the location of all proposed areas where the Applicant will conduct site work or
construction and the extent of ground disturbance (including staging areas, access roads, parking,
landscaping, grading or utilities)
☐ Photographs of the site
You have completed this schedule. Return to Section II.
FEMA COVID-19 Project Application Applicant-Assigned Project Application # ________
Last Updated: April 10, 2020 33
FEMA Public Assistance COVID-19 Contracts Report
Instructions: Applicants should complete one form for each PA COVID-19 project application.
Section I – Project Application Information
Declaration #:
Applicant Name: FEMA PA Code: Applicant-Assigned Project Application #:
Section II – Contract Information
Instructions: Applicants must complete this section to provide contract information for contract costs reported on the project application indicated in Section I of this form.
1. CONTRACT INFORMATION
Name of
Contractor
Contractor
EIN
Contract Award
Date
Contract Start
Date
Contract End
Date
Was the
contract
awarded
through a
competitive
bidding
process?
If not competitively bid,
please provide justification.
Please select one of the
following and write in the
box below:
Type of Contract
Please select one of
the following options
and write in the box
below:
Scope of Contract
For example, construction
of temporary facility or
emergency medical
transport.
Total
Contract
Award Please
indicate
dollar
amount.
Amount
requested for
funding on this
project
application
Please indicate
dollar amount.
☐ Yes
☐ No
☐ Only available from single source
☐ Public exigency or emergency
☐ FEMA authorized
☐ Recipient authorized
☐ Inadequate competition
☐ Other:
☐ Fixed price
☐ Cost-reimbursement
☐ Time and materials
☐ Cost-plus % of cost
☐ Other:
☐ Yes
☐ No
☐ Only available from single source
☐ Public exigency or emergency
☐ FEMA authorized
☐ Recipient authorized
☐ Inadequate competition
☐ Other:
☐ Fixed price
☐ Cost-reimbursement
☐ Time and materials
☐ Cost-plus % of cost
☐ Other:
☐ Yes
☐ No
☐ Only available from single source
☐ Public exigency or emergency
☐ FEMA authorized
☐ Recipient authorized
☐ Inadequate competition
☐ Other:
☐ Fixed price
☐ Cost-reimbursement
☐ Time and materials
☐ Cost-plus % of cost
☐ Other:
TOTAL
2. CERTIFICATION
I certify that the above information is accurate and was obtained from documents that are available for audit.
Applicant Authorized Representative Title Signature
4/3/20
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Submitting a Public Assistance Funding Request for COVID-19 (FEMA)

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Completed 22 May 2021

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