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Request for Public Assistance (RPA) Submission Page

FEMA Request for Public Assistance (RPA)

Step 1 of 3

33%

Paperwork Burden Disclosure
Public reporting burden for this data collection is estimated to average 15 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472, Paperwork Reduction Project (1660-0017) NOTE: Do not send your completed form to this address.
Privacy Act Statement
Authority: FEMA is authorized to collect the information requested pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 402-403, 406-407. 417, 423, and 427, 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e; The American Recovery and Reinvestment Act of 2009, Public Law No. 111-5, § 601; and “Public Assistance Project Administration,” 44 C.F.R. §§ 206.202, and 206.209.
Select Disaster Number*
Applicant Name (e.g. Town/City Name or Organization)*
Date Submitted*
MM slash DD slash YYYY
County (Location of Damages. If located in multiple counties, please indicate)*
- Belknap
- Carroll
- Cheshire
- Coos
- Grafton
- Hillsborough
- Merrimack
- Rockingham
- Strafford
- Sullivan
This field is hidden when viewing the form
(EXPIRED FIELD -HIDDEN) DUNS
Please Enter Your UEI Number*
On April 4, 2022, the federal government replaced DUNS numbers with the Unique Entity ID (UEI). DUNS numbers have now been removed from SAM.gov. Please log on to SAM.gov to find your new UEI number or register for one if you did not previously have a DUNS number or it had expired.
Applicant Employer Identification Number (EIN)*
Applicant Physical Location*
Street Address City State ZIP Code
Mailing Address (If different from Physical Location)
Street Address Address Line 2 City State ZIP Code
Primary Contact/Applicant's Authorized Agent
Name*
First Last
Title*
Business Phone*
Fax Number
Home Phone (Optional)
Cell Phone*
Email Address*
Pager and PIN Number (Optional)
Alternate Contact/Applicant's Authorized Agent
Name*
First Last
Title*
Business Phone*
Fax Number
Home Phone (Optional)
Cell Phone*
Email*
Pager and Pin Number (Optional)
This field is hidden when viewing the form
Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?*
- Yes
- No
Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?*
- Yes
- No
Private Non-Profit Organization?*
- Yes
- No
If Yes (PNP), which of the facilities identified below best describes your organization?*
Title 44 CFR, part 206.221(e) defines an eligible private non-profit facility as: "... any private non-profit educational, utility, emergency, medical or custodial care facility, including a facility for the aged or disabled, and other facility providing essential governmental type services to the general public, and such facilities on Indian reservations." "Other essential governmental service facility means museums, zoos, community centers, libraries, homeless shelters, senior citizen centers, rehabilitation facilities, shelter workshops and facilities which provide health and safety services of a governmental nature. All such facilities must be open to the general public."
Private Non-Profit Organizations must attach copies of their Tax Exemption Certificate and Organization Charter or By-Laws. If your organization is a school or educational facility, please attach information on accreditation or certification.*
Drop files here or

Accepted file types: pdf, jpg, gif, xslx, doc, docx, ppt, pptx, xsl, Max. file size: 1 GB.

Section II – Applicant Experience
1. What is the Applicant’s experience and level of support needed with the Public Assistance application process?*
Note: For State Led Disasters (including the COVID Disaster), each Applicant will be assigned a State Program Delivery Coordinator (SPDMG) to provide support throughout the grant process.
- Unfamiliar, and likely to need dedicated, in-person support navigating the process.
- Unfamiliar, but likely to be comfortable with limited or remote support navigating the process.
- Familiar, but likely to need dedicated, in-person support navigating the process.
- Familiar, and likely to be comfortable with limited or remote support navigating the process.
Section III – Impacts
Does the Applicant have any of the following incident-related impacts?
At least one type of incident-related impacts must be checked. (Select more than one, if applicable)
- Debris
- Emergency Response/Protective Measures
- Infrastructure Damage
What is the total approximate cost to address incident-related impacts?*
Numbers below valid for FFY 2023
- Less than $500,000
- Between $500,000 and $1,000,000
- $1,000,000 or more
What is the approximate total number of facilities with incident-related impacts?*
FEMA defines a facility as any publicly or privately owned building, works, system or equipment - built or manufactured - or an improved or maintained natural feature. Facilities may include public buildings, roads, bridges, drainage structures, parks, and flood control works. Land used for agricultural purposes is not a facility.
What is the status of all work to address incident-related impacts?*
- Work is completed and costs are documented.
- Work is completed and costs are not documented.
- Work has started. (provide a projected end date below)
- Work has not started.
Projected End Date of Work*
MM slash DD slash YYYY
Does the Applicant have any impacts that are of such severity that require immediate attention or federal support?*
- Yes
- No
For Impacts That Require Immediate Attention or Federal Support, Select All That Apply:
- Operations being conducted from temporary locations due to damaged facilities
- Damaged facilities that require temporary relocation of services
- Damaged facilities impact a substantial amount of the population
- Operations dependent on temporary equipment (such as generators or mobile boilers)
- Inaccessible areas
- Inaccessible facilities
- Other (Describe Below)
Other (Please Describe)*
Did an Applicant representative attend an Applicant Briefing?*
- Yes
- No

General Certifications
I certify that I have reviewed the following information regarding requirements to receive Public Assistance: (Select each to certify)
Applicants should document damages with photos and track all resources used at the site including dates and quantities.*
- I certify that I have reviewed the above information regarding requirements to receive Public Assistance
Applicants must comply with the applicable codes, specifications and standards requirements when restoring infrastructure.*
- I certify that I have reviewed the above information regarding requirements to receive Public Assistance
In accordance with the Public Assistance Program and Policy Guide, the Applicant must comply with applicable federal, state, and local laws must 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 must comply with any EHP compliance conditions placed on all grants.*
- I certify that I have reviewed the above information regarding requirements to receive Public Assistance
Applicants that utilize contractors for work conducted with FEMA PA funding must follow the procurement and contracting rules detailed in 2 CFR § 200.318-326.*
- I certify that I have reviewed the above information regarding requirements to receive Public Assistance

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