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STATE OF FLORIDA - JOINT HAZARD MITIGATION GRANT PROGRAM & <br /> FLOOD MITIGATION ASSISTANCE APPLICATION <br /> A. To Fill Out This Application : Complete All Sections That Correspond With The Type Of Proposed Project <br /> General Application Sections : pp. 2- 11 : All Applicants must complete these sections <br /> Maintenance Agreement: p. 12: All applications involving public property, public ownership, or management of property <br /> Acquisition Worksheet: pp . 14-16 : Acquisition Projects only -- one worksheet per structure <br /> Elevation Worksheet: pp. 17-22 : Elevation Projects only -- one worksheet per structure <br /> Drainage Worksheet: p. 23: Drainage Projects only (complete one application per project) <br /> Wind Retrofit Worksheet: pp. 24-26: Wind Retrofit Pmjects (HMGP only) one worksheet per structure <br /> Shelter Retrofit Worksheet: pp. 27-28: Shelter Retrofit Projects (HMGP only) one worksheet per structure <br /> Attachment A: FEMA Form 90-49 (Request for Public Assistance) : All Applicants must complete, if applicable. <br /> Attachment B : HMGP/FMA Application Completeness Checklist: All applicants are recommended to complete this checklist <br /> Be Applicant Information <br /> FEMA- -DR-FL Disaster name Ex. FEMA-1300-DR-FL : Hurricane Floyd <br /> Title / Brief Descriptive Project Summary Indian River Council on Aging Senior Center <br /> 1 . Applicant (Organization) Tndi an RiVpr CnUnty <br /> 2 , Applicant Type <br /> 1§ State or Local Government ❑ Recognized Native American Tribe t7 Private Non-Profit <br /> 3 . County Indian Rive _ <br /> 4 . State Legislative District(s) 80 Congressional District(s) 15 <br /> 5 . Federal Tax I. D . Number59-6000-674 <br /> 6 . FIPS Code* 061 -9906100 (* if your FIPS code is not known, please fill out FEMA Form 90-49 <br /> (Attachment A) so that the Department may obtain a FIPS code for you) <br /> 7 . National Flood Insurance Program (NFIP) Community Identification Number (this number can be obtained from the FIRM map <br /> for your area) 120124 <br /> 8 . NFIP Community Rating System Class Number __7 <br /> 9. Attach proof of current Flood Insurance Policy (FMA only) . Flood Insurance Policy Number 093276205980 Ol .. ._. <br /> 10. Point of Contact <br /> MMr. ❑Mrs . ❑Ms . First Name Jason Last Name Brown <br /> Title Budget Manager — Indian Riy_er.Lg. my or John King , Emergency Services <br /> Street Address 1840 25th St . _ <br /> City Vero Beach _ _ State FL Zip Code 32960 <br /> Telephone ( 772 ) 567 - 8000 Ext . 1214 Fax ( 772 ) 770 -5331 <br /> Email Address ( if available) ibrown@ircgov . com or iking@ircgov . com <br /> Continental Shelf Associates <br /> 11 . Application Prepared by: ❑Mr. ❑Mrs . OMs . First Name Last <br /> Title Telephone .5LJ-246 7946 Fax 561 -747-2954 <br /> 12. Duly Authorized Representative (proof of authorization authority to sign contracts required) <br /> 1AMr. ❑Mrs . OMs . First Name Kenneth Last Name Macht <br /> Title Chairman Telephone772 - 567 - 8000 Fax 772 - 770 - 5334 <br /> Street Address 1840 25th Ste Ext . 1490 <br /> City Vero BeAcii State FL Zip Code 32960 <br /> Signature Date 8 / 19 / 2003 <br /> *Pleas o : The above line item number (12) mus a signed by an individual with Iegal signing authorityfor the respective <br /> local government or county (e.g. , the Chairperson, Board of County Commissioners or the Mayor, etc.) <br /> 13. All proposed projects should be included in the county's Local Mitigation Strategy (LMS), please attach a letter of <br /> endorsement for the project from the county's Local Mitigation Strategy Coordinator, <br /> 2 <br /> Attach any continuations or additional items to this page <br />