Please submit one paper copy and one Word copy of the application for each proposed project

This application is for Hazard Mitigation Grant Program (HMGP) warning and communication proposals administered by the Georgia Emergency Management Agency (GEMA). Please complete all sections and provide all information as requested. Incomplete applications will be removed from further consideration. It is important that you answer every question. If you require assistance with this application, please contact the Risk Reduction Specialist assigned to your area at 1-800-TRY-GEMA.

1. Application Title / Brief Project Description ____________________________________________________

________________________________________________________________________________________________

__________________________________________________________________________________________________

2. Applicant (Organization)

3. Applicant Type State or Local Government Recognized Indian Tribe Private Non-Profit

State Legislative District(s) Federal Congressional District(s)

Federal Tax I.D. Number DUNS Number FIPS Code:__________

4. National Flood Insurance Program (NFIP) Community Identification Number

5. NFIP Community Rating System Class Number

6. Application Prepared by

Ms. Mr. Mrs. First Name ______________________Last Name___________________________

Title ___________________________________________Telephone __________________________

Street Address_______________________________________________________________________

City_____________________________________ State _______ Zip Code__________________

E-mail address: _______________________________________________________________________

1 Rev. 11/5/14

THIS SECTION FOR STATE USE ONLY

FEMA-_____-DR-

Conforms to State Mitigation Plan Eligible Applicant Project Type Conforms to Local Mitigation Plan State or Local Government Acquisition Elevation Project Pre-Identified in Local Plan Private Non-Profit Wind Flood Declared Area Tornado Statewide

Community NFIP Status: Participating Community ID #: _________________ In Good Standing Non-Participating CRS

State Application ID# __________________________ Date Application Received ______________________

State Reviewer______________________________ Signed____________________________ Date __________

FEMA Application Hardcopy Submittal Date: __________________________

FEMA Application Completed NEMIS Entry Date: ______________________

7. Authorized Applicant Agent (An individual authorized to sign financial and legal documents on behalf of the local government (e.g., the Chairperson, Board of County Commissioners, or the County Manager, etc.)

a. Ms. Mr. Mrs. First Name _________________ Last Name___________________________

b. Title ______________________________Telephone ___________________________________

c. Street Address_________________________________________________________________

d. City____________________________________ State _______ Zip Code______________

e. E-mail address

8. This project must be identified in your Local Mitigation Plan. Provide excerpts from your approved Plan with the goals, objectives that supports your project. Also attach recommendation letter from your County EMA Director.

____________________________________________________________________

_____________________________________________________________________________________

9. Date of County Hazard Mitigation Plan Approval: _____________________________

Attach any continuations or additional items to this page Rev. 12/8/08

2

I. History of Hazards / Damages in the Area to be Protected*Provide a detailed past history of damages in your community for your specific mitigation action. , You can use the following web site for details if you do not have them available. http://www4.ncdc.noaa.gov/cgi-win/wwcgi.dll?wwevent~storms

Date Description of Event Direct Damages Indirect Damages (describe) Ex. 1 - 10/7/89 Spring floods of 1985 Total of $95,000 in damages Emergency Services –

to 16 homes in project area evacuation of 58 people.

II. Hazards to be Mitigated / Level of Protection

1. Select the type of hazards the proposed project will mitigate:

Flood Wind Seismic Tornado Other (list) ___________________

2. Identify the type of proposed project:

Siren Mass Alert Weather Radios

3. List the total number of persons that will be protected by the proposed project:_______________

4. Useful life: The project will provide protection against the hazard(s) above for _________years.

5. Protection Provided: Describe, in detail, the existing problem. Explain how the proposed project will solve the problem and provide the level of protection.

III. Project Location1. Name and physical address (including city, state, county and zip code).

Digital Latitude: __________________ Digital Longitude:__________________

Year Built: _____________

2. Flood Insurance Rate Map (FIRM) showing Project Site Include copy FIRM map. VE or V 1-30 AE or A 1-30 AO or AH A (no base flood elevation given) B or X (shaded) C or X (unshaded) Floodway Coastal Barrier Resource Act (CBRA) Zone

3. City or County Map with Project Site and Photographs

Include Google map with the project site clearly marked.

Include color photographs showing a front view, a side view, a back view and a street view of the structure.

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IV. Scope of Work / BudgetDo not include contingency costs in the budget. List all anticipated costs in detailed. Consider the potential future date of construction when compiling the cost estimate. Please provide documentation for each of your budget items such as potential vendor estimates, etc.

Item Description

Unit Quantity Unit Price Amount Source

Total Estimated Project Cost $____________________

V. Funding Sources The maximum FEMA share for HMGP projects is 75 percent. The other 25 percent can be made up of State and Local funds as well as in-kind services. HMGP funds may be packaged with other Federal funds, but other Federal funds (except for Federal funds which lose their Federal identity at the State level – such as CDBG, ARS, HOME) may not be used for the State or Local match.

Estimated FEMA Share $ % of Total (75%)Non-Federal Share

Estimated Local Share $ % of Total (15%)

Estimated State Share $ % of Total (10%)

Total Project Costs $ 100% of Total

VI. Project Implementation Narrative:

In one or two paragraphs, please detail what activities and who will perform the activities needed to complete this project.

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VII. Project Work ScheduleEnter the steps you will need to take to complete the project from start to finish and the number of days each step will require to complete. Include the time required pre-construction steps such as project design, bidding and bid award and project close-out. The days should be counted from the start of the project through the completion of the task. Certain work activities may run concurrently.

)

Work ItemNumber of Days to

Complete

                                                                                                              

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Environmental Impacts of Proposed Project and Alternatives

Because HMGP is a federally funded program, all projects are required to undergo an environmental and historic preservation review as part of the grant application process. All projects must comply with the National Environmental Policy Act (NEPA) and associated Federal, State, and Local statutes to obtain funding. NO WORK can be done prior to the NEPA review process. If work is done on your proposed project before the NEPA review is completed, it will NOT be eligible for Federal funding.

The following information is required for the Environmental and Historic Preservation review. All projects must have adequate documentation to determine if the proposed project complies with NEPA and associated statutes.

Alternative Actions

The NEPA process requires that at least two alternative actions be considered that address the same problem/issue as the proposed project. In this section, list two feasible alternative projects to mitigate the hazards faced in the project area. One alternative is the “No Action Alternative”. This application cannot be processed if this section is incomplete.

A. No Action AlternativeDiscuss the impacts on the project area if no action is taken.

B. Other Feasible Alternative Discuss other feasible alternatives to the proposed project. This could be an entirely different mitigation

method or a significant modification to the design of the current proposed project.

Hazards to be Mitigated / Level of Protection

1. Select the type of hazards the alternative project will mitigate: Flood Wind Seismic Other (list) ___________________

2. Identify the type of alternative project:__________________________________________________________________________ ___________________________________________________________________________

Useful life of the alternative project _________ years

Does alternative project conform to local mitigation plan _____Yes _____No

Is alternative project pre-identified in local mitigation plan? _____Yes _____No

C. Alternative Project Description / Protection ProvidedDescribe, in detail, the existing problem. Explain how the alternative project will solve the problem and provide the level of protection described in Section II A(4).

D. Alternative Project LocationDescribe the location of the alternative project.1. Site

a. Physical Location Describe the area and/or population affected/protected by this project, include the location (street numbers or neighborhoods) and zip codes. If possible, please provide precise longitude and latitude coordinates for the site utilizing a hand-held global positioning system (GPS) unit or use website http://terraserver-usa.com/default.aspx . Include maps showing location.

b. Population Affected

Provide the number of people impacted in the project area.

__________ 6

Rev. 11/5/14

City or County Map with Project Site and Photographs

Include Google map with the project site clearly marked.

Include color photographs showing a front view, a side view, a back view and a street view of the structure.

.

E. Alternative Scope of Work / Budget List all anticipated costs in detail. Consider the potential future date of construction when compiling the

cost estimate. Please provide documentation for each of your alternative budget items such as vendor estimates, etc.

Item Description

Unit Quantity Unit Price Amount Source

Total Estimated Project Cost $____________________

F. Alternative Project Work Schedule (List timeline for the completion of this project:

Description of Task Number of Days to Complete Work Completed By Ex. Demolition of 6 structures and removal of debris 14 days Demolition Contractor

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National Environmental Policy Act (NEPA) Documents for SirensAll projects that receive Federal funding must comply with NEPA and associated Federal, State, Tribal, and local statutes. NO WORK can be done on proposed projects before the NEPA review is complete.

If your project is one of the following, no additional NEPA documents are required.1) Development of Mitigation Plans 2) Studies involving only staff time and funding

3) Purchase of warning communications equipment or services (excluding sirens)All applications must have adequate NEPA documents that enable the FEMA Regional Environmental Officer to determine NEPA compliance. The type and quantity of NEPA documents required to make this determination varies depending upon the project’s size, location, and complexity. However, at a minimum, all proposed projects must include the following NEPA documents:

Attach the following NEPA documents for the proposed project: A letter from the State Historic Preservation Officer (SHPO) regarding cultural resources (archeological and historic) in

the project area, and the proposed project’s likely effects on these resources. (See sample coordination letter enclosed) A letter from the U.S. Fish and Wildlife Service regarding fish and wildlife, Federal-listed Threatened or Endangered

plant or animal species, their habitat, and if applicable, actions required to mitigate (off-set) the project’s adverse effects.

A letter from the State Wildlife Resources regarding State-listed Threatened or Endangered plant and animal species, their habitat, and if applicable, actions required to mitigate the project’s adverse effects.

SAMPLE SHPO COORDINATION LETTER

DateDr. David CrassDivision DirectorRev. 11/5/14 8

Attn: Elizabeth ShirkEnvironmental Review Coordinator254 Washington Street, SW Ground LevelAtlanta, Georgia 30334

Dear Dr. Crass:

(Your Jurisdiction Name here) has applied to the Georgia Emergency Management Agency for a Hazard Mitigation Assistance grant. The HMA program requires a letter from the State Historic Preservation Officer regarding cultural resources (archeological and historical) in the project area and the project’s likely effects on those resources.

This project is located in (Your Jurisdiction Name here) at (address of project). The intent of this project is to (enter description of project here). Maps and photographs of the proposed project area are enclosed for your use. If you have any questions or comments, please do not hesitate to contact me at (enter telephone and email address here)

Sincerely,

(your name and title here)

Enclosurecc: Natalie Jones

Hazard Mitigation DivisionGeorgia Emergency Management Agency

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SAMPLE GA DNR COORDINATION LETTER

Date

Ms. Katrina MorrisEnvironmental Review CoordinatorNongame Conservation SectionGeorgia DNR, Wildlife Resources Division2065 U.S. Hwy. 278, SESocial Circle, GA 30025

Dear Ms. Morris:

(Your Jurisdiction Name here) has applied to the Georgia Emergency Management Agency for a Hazard Mitigation Assistance grant. The HMA program requires a coordination letter regarding State-listed Threatened or Endangered plant and animal species

This project is located in (Your Jurisdiction Name here) at (address of project). The intent of this project is to (enter description of project here). Maps and photographs of the proposed project area are enclosed for your use.

The approximate date of initiation of activities on this project is approximately 18 months from the date of this letter. If you have any questions or comments, please do not hesitate to contact me at (enter telephone and email address here).

Sincerely,

(Your name and title here)

Enclosurecc: Natalie Jones

Hazard Mitigation DivisionGeorgia Emergency Management Agency

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SAMPLE US FISH AND WILDLIFE COORDINATION LETTER

Date

Chief Endangered Species U.S. Fish and Wildlife ServicesEnvironmental Protection Division1875 Century Boulevard, Suite 200Atlanta,, GA 303454

Dear Sir/Madam:

(Your Jurisdiction Name here) has applied to the Georgia Emergency Management Agency for a Hazard Mitigation Assistance grant. The HMA program requires regarding fish and wildlife, Federal-listed Threatened or Endangered plant or animal species, their habitat in the project area.

This project is located in (Your Jurisdiction Name here) at (address of project). The intent of this project is to (enter description of project here). Maps and photographs of the proposed project area are enclosed for your use.

The approximate date of initiation of activities on this project is approximately 18 months from the date of this letter. If you have any questions or comments, please do not hesitate to contact me at (enter telephone and email address here).

Sincerely,

(Your name and title here)

Enclosurecc: Natalie JonesHazard Mitigation DivisionGeorgia Emergency Management Agency

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MAINTENANCE AGREEMENT

All applicants whose proposed project involves the retrofit or modification of existing public property or whose proposed project would result in the public ownership or management of property, structures, or facilities, must first sign the following agreement prior to submitting their application to FEMA.

(NOTE: Those applicants whose project only involves the retrofitting, elevation, or other modification to private property where the ownership will remain private after project completion DO NOT have to complete this form.)

The ________________ of __________________________, State of ________________, hereby agrees that (City, Town, County) if it receives any Federal aid as a result of the attached project application, it will accept responsibility, at its own expense if necessary, for the routine maintenance of any real property, structures, or facilities acquired or constructed as a result of such Federal aid. Routine maintenance shall include, but not be limited to, such responsibilities as keeping vacant land clear of debris, garbage, and vermin; keeping stream channels, culverts, and storm drains clear of obstructions and debris; and keeping detention ponds free of debris, trees, and woody growth.

The purpose of this agreement is to make clear the Subgrantee’s maintenance responsibilities following project award and to show the Subgrantee’s acceptance of these responsibilities. It does not replace, supercede, or add to any other maintenance responsibilities imposed by Federal law or regulation and which are in force on the date of project award.

Signed by __________________________________________the authorized applicant agent(printed or typed name of signing official)

____________________________________of ________________________________________,(title) (name of applicant)

this _____________(day) of ______________ (month), ___________(year).

Authorized Applicant Agent’s Signature*______________________________* An individual authorized to sign financial and legal documents on behalf on the local government (e.g., the Chairperson, Board of County

Commissioners or the County Manager, etc.)

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APPLICATION FOR OMB Approval No. 0348-0043

FEDERAL ASSISTANCE 2. DATE SUBMITTED

    

Applicant Identifies

     1. TYPE OF SUBMISSION

Application Construction Non-

Construction

Pre-application Construction Non-

Construction

3. DATE RECEIVED BY STATE

     

State Application Identifier

     4. DATE RECEIVED BY FEDERAL AGENCY

     

Federal identifier

     5. APPLICANT INFORMATIONLegal Name:       Organization Duns:      Address (give city, county, State, and zip code):          

Name and telephone number of person to be contacted on matters involving this application (give area code)

           6. EMPLOYER INDENTIFICATION NUMBER (EIN):

     

     

     

     

           

     

     

     

7. TYPE OF APPLICANT: (enter appropriate letter in box)

8. TYPE OF APPLICATION: New Continuation

Revision

If Revision, enter appropriate letter (s) in box(es)

     

     

9. NAME OF FEDERAL AGENCY:

Federal Emergency Management Agency

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER

9 7 — 0 3

12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):      13. PROPOSED PROJECT

14. CONGRESSIONAL DISTRICT OF:

Start Date

     Ending Date

     

a. Applicant

     b. Project

     

15. ESTIMATED FUNDING:

a. Federal$      

.00

b. Applicant$      

.00

c. State$      

.00

d. Local$      

.00

e. Other$      

.00

17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?

g. TOTAL$      

.00 YES If “Yes,” attach an No

Rev. 11/5/14

A. State H. Independent School Dist.B. County I. State Controlled Institution of Higher LearningC. Municipal J. Private UniversityD. Township K. Indian TribeE. Interstate L. IndividualF. Intermunicipal M

.Profit Organization

G.

Special District N. Other (Specify)

A. Increase Award B. Decrease Award C.

Increase Duration

D. Decrease Duration Other (specify):

13

explanation18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.a. Type Name of Authorized Applicant Agent

     b. Title

     c. Telephone Number

     d. Signature of Authorized Applicant Agent e. Date Signed

     

ASSURANCES – CONSTRUCTION PROGRAMS

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0042), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the Awarding Agency. Further, certain Federal assistance awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.

As the duly authorized representative of the applicant, I certify that the applicant:

1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability including funds sufficient to pay the non-Federal share of project costs to ensure proper planning, management and completion of the project described in this application.

2. Will give the awarding agency, the Comptroller General of the United States and, if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the assistance; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives.

3. Will not dispose of, modify the use of, or change the terms of the real property title, or other interest in the site and facilities without permission and instructions from the awarding agency. Will record the Federal interest in the title of real property in accordance with awarding agency directives and will include a covenant in the title of real property acquired in whole or in part with Federal assistance funds to assure non-discrimination during the useful life of the project.

4. Will comply with the requirements of the assistance awarding agency with regard to the drafting, review and approval of construction plans and specifications.

5. Will provide and maintain competent and adequate engineering supervision at the construction site to

ensure that the complete work conforms with the approved plans and specifications and will furnish progress reports and such other information as may be required by the assistance awarding agency or state.

6. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.

7. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain.

8. Will comply with the Intergovernmental Personnel act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM’s Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).

9. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§4801 et seq.) which prohibits the use of lead-based paint in construction or rehabilitation of residence structures.

10. Will comply with all Federal statutes relating to non-discrimination. These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or national origin; (b)

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Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which prohibits discrimination on the basis of Sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act f 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee-3), as amended, relating to confidentially of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the requirements of any other nondiscrimination statute(s) which may apply to the application.

11. Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal and federal-assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases.

12. Will comply with the provisions of the Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds.

13. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§327-333) regarding labor standards for federally-assisted construction subagreements.

14. Will comply with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000 or more.

15. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of Federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §§7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (PL. 93-523); and, (h) protection of endangered species under the Endangered Species Act of 1973, as amended (P.L. 93-205).

16. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.

17. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. §470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§469a-1 et seq.).

18. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, “Audits of States, Local Governments, and Non-Profit Organizations.”

19. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations, and policies governing this program.

SIGNATURE OF AUTHORIZED APPLICANT AGENT TITLE

APPLICANT ORGANIZATION DATE SUBMITTED

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SF-424D (Rev. 7-97) Back

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