Okaloosa County BOCC — July 15, 2014 — MX-2300N_20140709_114908 — reading text

DEPARTMENT GF HOMELAND SEGURITY FEDERAL EMERGENCY MANAGEMENT AGENCY REQUEST FOR PUBLIC ASSISTANCE PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 10:minutes. Burden means the time, effort and financial resources expended by persons to generate, maintain, disclose, or to. provide information to us. You may send comments regarding the burden estimate-or any aspect of the collection, including suggestions for feducing the burdén to: Infomation Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (OMB Control Number 1660-0017). You are not required to respond to this collection of information unless it displays a. valid OMB number. NOTE: Do not'send your completed questionnaire to this address. O.M.B. NO; 1660-0047 Expires Aprif 30, 2013 APPLICANT (Political subdivision or eligible applicant) DATE SUBMITTED Okaloosa County May 22, 2014 COUNTY (Location of Damages: [flocated in multiple counties; please indicate) DUNS NUMBER Okaloosa 613277649 APPLICANT PHYSICAL LOCATION STREET ADDRESS 1804 Lewis Turner Blvd., Suite 206 cITy COUNTY : STATE ZIP CODE Fort Walton Beach Okaloosa FL 32547 MAILING ADDRESS (If different from Physical Location) STREET ADDRESS 1804 Lewis Turner Blvd., Suite 206 POST OFFICE BOX CITY STATE ZIP CODE Fort Walton Beach FL 32547 Primary Contact/Applicant's Authorized Agent Alternate Contact NAME - NAME : Marcella Eubanks Gary Stanford THLE. THLE Contracts & Grants Manager Finance Director BUSINESS PHONE BUSINESS PHONE 850-651-7200 ext. 4381 850-689-5000 ext. 3411 FAX. NUMBER FAX NUMBER’ 850-609-5029 850-689-5818 HOME PHONE (Optional) : HOME PHONE (Optiorial) CELL PHONE CELL PHONE 850-585-6245 E-MAIL ADDRESS E-MAIL ADDRESS meubanks@clerkofcourts.cc gstanford@clerkofcourts.cc PAGER & PIN NUMBER PAGER & PIN NUMBER Title 44 CFR, part 208.221 (e)-defines an eligible private non-profit facility as: "... any private non-profit educationai, utility, emergency, medical or custodial caré facility; including a facility for the aged or disabled, and other facility providing essential governmental type services tothe general public, and such facilities:on Indian reservations." "Other essential governmental sefvite facility means museums, zoos, community centers, libraries, homéless shelters, senior citizen centers, rehabilitation facilities, shelter workshops and facilities which provide health and safety safety services of a governmental nature. All such facilities must be-open to the general public.” Private Non-Profit Organizations must attach copies of their Tax Exemption Certificate and Organization Charter or By-Laws. If your organization is ‘a school or educational facility, please attach information on accreditation or certification. OFFICIAL USE-‘ONLY: FEMA- 4177 - PA - FL - FIPS#091-99091-00 DATE RECEIVED May 22, 2014 FEMA Form 90-49 AUG 10 REPLACES ALL PREVIOUS EDITIONS