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Attachment 3 <br /> DEPARTMENT OF HOMELAND SECURITY Cp.NLB.No.1660-0017 <br /> FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> REQUEST FOR PUBLIC ASSISTANCE Fxpires Odtiher 3t;2t10R <br /> PAI'I+;RWORK 13IJiZ1lH:N DI.`%0,0:SCIRE N( I'iCaV <br /> Public reporting burden for this forum is estimated to average 10 minutes. Burden means the time,effort and financial resources <br /> expended by persons to generate,maintain,disclose,or to provide information to tits You may send comments regarding;the burden <br /> estimate or any aspect of the collection including suggestions for reducing the burden toInformation Collections Management,ITS: <br /> Department of Homeland SecunFederal Emergency Management Agency,500 C Street,ALU,Washington,DC 20472,Pag�erwvorlr <br /> Deduction Prpicet(C Nffl Contra lumber 1660-0017). You are not required to respond to this collection of information ut cs a <br /> valid C-} number appears in the zipper right corner of this form. NOTE:Do not send your completed questionnaire to this <br /> address. <br /> APPL ICA N I Wolitical sub cffvislon orcligibfe applicant.) DA I L SUBMI I ILD <br /> C:C3LDNTY(f nrnranra r5f I7hanar�Qs_ tf lnr;�rP,aN iia rrartttl)ilp crar�ntieas,,nl�aasa frrrlfr�re�.1 <br /> APPLICANT PHYSICAL LOCATION <br /> S I&SEL I ADDRESS <br /> CITY COUNTY STATC 71PCODE <br /> MAILING ADDRESS ff different fruits Pfi s cat Locatkn <br /> STREET ADDRESS' <br /> POST OFFIC:F BOX CITY STATF 71PCODF <br /> PrimarX Contact AA" I9cant"sAuthorized Agent Altemate Contact <br /> NAME NAME <br /> 111 1.9- I I I I I, <br /> BUSINESS PHONE BUSINESS PHONE <br /> FAX NUMRFR FAX NUMRFR <br /> HOME PHONE(Optional) HOME PHONE(Optional) <br /> CELL PHONE CELL PHONE <br /> E MAIL ADDRESS E MAIL ADDRESS <br /> PACER&PIN NUMBER PAGER& PIN NUMBER <br /> Did you participate its the Federal/State Preliminary Damage Assessment(PDA)? 13yes ®No <br /> Primate Nuri-Profit Organization? Ycs L1 No <br /> Ifyes,which of the facilities identified helowv hest describe your organiz.Eation'I <br /> Title 44(FR,part 206.221(e)defines an eligible private roti-profit facility as:`--.any private non-profit educational,utility,emergency,medical or <br /> custcxhal care fiacihty,including a.rrcuhty for the aged or chsabled,and tallier facility providing essential govern mrital type services to the gener l <br /> public,and such facilities an lnd an reservations" ,Cithcr csselztttal governinental s rvrce facility means nittsctuns,zoos,Conuirrulity ecntcrs;tibrancs <br /> hoTneless shelters,serauar Custer ceratf s,T01abilI1111i`an ratiIalses,sl aellea workshops s aaad flacilihUs'An eh provide health and safely services tat'a <br /> governmental:nature, All such facrlitics must be opcit to the gf.9acral public::" <br /> PrivAte Non-Prolit Organizations must attach copies of their 1 ax Exemption Certificate and Or eniralion Charter or By Law& <br /> If your organization is a school or educational facility,phase attach latformation on accreditation or certification. <br /> Official Use Only: FEMA-` -DR- PIPS# late Recelved: <br /> FEMA Form 90-49, FEB OD REPLACES ALL PREVOUS EDITIONS, <br /> Indian River County Comprehensive Emergency Management Plan Annex IA- Page 30 <br />