Hazard Mitigation Assistance Pre-Application

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* 1. Agency Information

Agency Name

Address Line 1

Address Line 2

City/Town

ZIP/Postal Code

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* 2. Point of Contact Information

Phone

Email

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* 3. Will your agency require any technical assistance in regards to this application?

No

Yes (please describe)

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* 4. Does your community participate in the NFIP?

Yes

No

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* 5. Does your community have a FEMA approved mitigation plan?

Yes

No

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* 6. Mitigation Project Type

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* 7. Project Description

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* 8. Project Alternatives (List 2 alternatives and describe why the project you are proposing is the best solution)

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* 9. Project Location

Address Line 1

Address Line 2

City/Town

Zip Code

Latitude

Longitude

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* 10. Structural Information (If applicable)

Year Built

Square Footage

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* 11. Does this property have flood insurance?

Yes

No

N/A

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* 12. Estimated Project Cost

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* 13. Matching Funds Source

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* 14. Local/State Mitigation Plan Goal Supported

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* 15. Local/State Mitigation Plan Action Supported

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* 16. Does this project involve any Repetitive Loss or Severe Repetitive Loss Properties?

Yes

No

Unsure