Hazard Mitigation Assistance Reimbursement Request Form

This Reimbursement Form is intended for Pre-Disaster Mitigation (PDM), Building Resilient Infrastructure and Communities (BRIC), Hazard Mitigation Grant Program (HMGP), Rehabilitation of High Hazard Potential Dam (HHPD), and Flood Mitigation Assistance (FMA).

Before you begin this request, please make sure you have completed the Reimbursement Request Letter as you will be uploading this below.

A sample letter can be found here (copy and paste link):
https://prd.blogs.nh.gov/dos/hsem/wp-content/uploads/2014/11/SAMPLE-REQUEST-FOR-REIMBURSEMENT-LETTER-1.docx
Contact Information
Sub-Recipient Name (City/Town/Entity Name/RPC)(Required)
Primary Point of Contact (POC)(Required)
First Last
Primary POC Email(Required)
Primary POC Phone(Required)
Project Information
Grant Program (leave blank if unsure)
Disaster Declaration (DR)(Required)
Federal Fiscal Year (FFY)(Required)
Project Name(Required)
Hidden
Is this reimbursement request for Management Costs?(Required)
- Yes - this reimbursement is for Management Costs
- No
Amount of Reimbursement Request(Required)
Hidden
Total Amount for this Reimbursement Request(Required)
This is the 100% cost for the reimbursement.
Hidden
Federal Share
75% of Total Amount for this Reimbursement Request
Hidden
Non-Federal Share
25% of Total Amount for this Reimbursement Request
Hidden
Federal Share
65% of Total Amount for this Reimbursement Request
Hidden
Non-Federal Share
35% of Total Amount for this Reimbursement Request
Hidden
Federal Share
Management Costs have a 100% Federal Share.
Hidden
Non-Federal Share
Management Costs have a 0% Non-Federal Share.
Documentation Upload
Reimbursement Request Letter(Required)
A REIMBURSEMENT REQUEST LETTER IS REQUIRED FOR ALL REIMBURSEMENTS. THIS MUST BE ON OFFICIAL LETTERHEAD OF THE ORGANIZATION RECEIVING THE FUNDS.

Example: if your grant agreement identifies the Fire Department as receiving the funds, the letterhead must be on the Fire Department's letterhead, not the generic town's letterhead. Please upload your signed reimbursement request letter.

A sample letter can be found here (copy and paste link):
https://prd.blogs.nh.gov/dos/hsem/wp-content/uploads/2014/11/SAMPLE-REQUEST-FOR-REIMBURSEMENT-LETTER-1.docx
Max. file size: 1 GB.
Additional Supporting Files
Proof of cost, proof of payment, timesheets, etc.
Drop files here or

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

Max. file size: 1 GB.
Hidden
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.
Hidden
What is the form of the non-federal share?(Required)
- Cash
- In-Kind
- Both - combination of cash and in-kind
Hidden
Match Documentation
Please upload all documentation related to the local match portion of the project.
Drop files here or

Max. file size: 1 GB.
Hidden
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 Point of Contact (POC)(Required)
- Yes
- No
Name of Person Completing Request(Required)
First Last
Email of Person Completing Request(Required)
Phone Number of Person Completing Request(Required)
By selecting the box below and entering my name and today's date, I agree and understand that failure to request reimbursement by the deadline or 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.(Required)
- 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.(Required)
- I understand and agree
Date(Required)
MM slash DD slash YYYY
Name(Required)
First Last
Hidden
Email(Required)
Enter Email Confirm Email
Comments
Provide any additional comments or notes that you would like to share with HSEM regarding this request.
Name
This field is for validation purposes and should be left unchanged.

Hazard Mitigation Assistance Reimbursement Request Form

Contact Information

Project Information

Documentation Upload

Certification and Submission