Public Assistance Reimbursement Request Form

Please review the requirements of this form before submission:

Please view thePublic Assistance Program and Policy Guide (PAPPG) Documents Table to see a list of information required for reimbursement. You must include all of the relevant information in your request.
Also, you must complete a Request for Reimbursement Letter that will be uploaded into the form below. The letter must include the Damage Inventory numbers that are associated with each invoice, proof of payment, etc. A sample letter can be found at this link: Public Assistance Reimbursement Request Letter.
You will need to confirm on this submission that you have followed all procurement policies and federal procurement requirements. Please view the FEMA Public Assistance Procurement Requirements (click here) document and notify HSEM if you have questions.

For Management Costs Projects ONLY

All Management costs projects (Category Z) must include the Management Cost Tracking Spreadsheet (Click Here). This spreadsheet includes the required information to process your reimbursement. Please download the sheet, complete it, and upload it to this form.

Public Assistance Reimbursement Request

Contact Information
Sub-Recipient Name (Municipality/Entity Name)*
Primary Point of Contact (POC)*
First Last
Primary POC Email*
Enter Email Confirm Email
Primary POC Phone*
Project Information
Please Select Reimbursement Type*
- Management Cost Reimbursement
- Large Project Reimbursement
Do you wish to pursue a Category Z Management Cost project?*
- Yes, I wish to pursue reimbursement
- No, I do not wish to pursue reimbursement
Is there already an existing Category Z project in Grants Portal?
- Yes
- No
Disaster (DR) Number*
Project Title*
EMMIE Project Number*
Please enter a number from 0 to 500.
Grants Portal Project Number*
Please enter a number from 0 to 999999.
Project Category of Work*
Total Amount for this Reimbursement Request*
This is the amount being requested for reimbursement.
Is this project 100% complete?*
- Yes, this project is 100% complete
- No, additional work still needs to be completed/is ongoing
Is this reimbursement request submission the last one for this project?*
- Yes, the work is complete and this is the last reimbursement request
- No, this is not the last reimbursement request for this project. Additional requests will be submitted at a later date.
Documentation Upload
Reimbursement Request Letter
Please upload your request for reimbursement on town letterhead.
Drop files here or

Max. file size: 1 GB.
Proof of Cost
Please upload all documentation related to the cost of the project (i.e., vendor invoices)
Drop files here or

Max. file size: 1 GB.
Proof of Payment
Please upload all documentation related to the payment of the above invoices (i.e., copies of cancelled checks, bank statements, credit card statements)
Drop files here or

Max. file size: 1 GB.
Additional Supporting Documentation
Please provide any additional documentation for the reimbursement request here (i.e. task based narrative).
Drop files here or

Max. file size: 1 GB.
Certification and Submission
The person completing this reimbursement request is the same as the Primary POC*
- Yes
- No
Name of Person Completing Request*
First Last
Email of Person Completing Request*
Enter Email Confirm Email
Phone Number of Person Completing Request*
By selecting the box below and entering my name, I agree and understand that providing any false information may result in the inability to distribute any further monies or benefits related to this project until a complete and accurate report has been sent to NH HSEM. In addition, failure to request reimbursement on time may result in the loss of future funding/grant awards.*
- I understand and agree
By selecting the box below and entering my name, I certify that the projects for which management costs are being claimed are eligible in accordance with FEMA regulations and the Interim Policy.*
- I Understand and Agree
By selecting the box below and entering my name, I certify that the contracted costs associated with this project(s) reimbursement have been acquired in full accordance with my entity's procurement policy and the federal procurement requirements found in 2 CFR §200. I also understand that in the absence of an agreed upon procurement policy for my entity, I certify that I have followed the federal procurement requirements found in 2 CFR §200.*
- I Understand and Agree
Name*
First Last
Comments
Provide any additional comments or notes that you would like to share with HSEM regarding this request.
Comments
This field is for validation purposes and should be left unchanged.