New Hampshire Public Assistance Withdrawal Form

Public Assistance Withdrawal Form

This form is used to notify the State of New Hampshire of an Applicant's desire to withdraw either a project or a damage inventory line item from a disaster, or to withdraw from a disaster as a whole.

Contact Information
Subrecipient Authorized Representative Name*
First Last
Title within Organization*
Email*
Enter Email Confirm Email
Phone*
Withdrawal Information
Disaster*
Select the Disaster this Withdrawal Form is for.
Disaster - Other*
Applicant Organization Name*
PA-ID Number*
This information can be found on the FEMA Grants Portal under your Subrecipient Organization Page
Project Number OR Damage Inventory Number OR Disaster Number Being Withdrawn*
Please enter either one of the following numbers:
- The Project Number of the project you with to withdraw (if the entire project is being withdrawn)
- The Damage Inventory number (if only withdrawing a portion of a project)
- The Disaster Number (if withdrawing from the entire disaster process for one event)
Please select the reason for this withdrawal:*
- No eligible damage
- Damage below FEMA's required minimum Small Project Threshold
- No longer wish to pursue Federal assistance from FEMA
- Decision not to pursue Administrative Costs (PAAP DAC or Management Costs) - Category Z Projects Only
- Other (please explain)
Other*
Please explain the reason for the withdrawal request
Digital Signature and Certification
I understand that by submitting this form, I am requesting that the above damages and/or projects are removed from my application for funding from FEMA's Public Assistance Program.*
- I Understand
I understand that this action will have no impact on obtaining federal assistance for future disaster events.*
- I Understand
Subrecipient Authorized Representative Name*
Date Form Completed (Subrecipient)
MM slash DD slash YYYY

New Hampshire Public Assistance Withdrawal Form

Public Assistance Withdrawal Form

Contact Information

Withdrawal Information

Digital Signature and Certification