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<br />FEDERA ..i ,'E.RGENCY MANAGEMENT AGENCY
<br />PRELIMINARY DAMAGE ASSESSMENT SUMMARY
<br />PART I - APPLICANT INFORMATION
<br />NAME OF APPLICANT NAME OF LOCAL CONTACT
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<br />TOTAL BUDGET MAIN NANce B GET
<br />APproved $ Bal.nee $ Approved $ Balance $
<br />PART II - COST ESTIMATE-SUMMARY (COMPLETE SITE ESTIMATE BEFORE SUMMARIZING BELOW)
<br />POTENTIAL LOCAL FUNDS FOR RECOVERY
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<br />DATE
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<br />COUNTY
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<br />OPULATION
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<br />PHONE No.i'~ -
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<br />DATE FY BeGINS
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<br />CA TE- NO. OF
<br />GORY SITes
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<br />TYPES OF DAMAGe
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<br />COST ESTIMATE
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<br />FUND/ACCOUNT
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<br />.. AVAILABLE BALANCE
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<br />PART III - DISASTER IMPACTS (USE SEPARATE SHEETS IF NECESSARY)
<br />
<br />A. GENERAL IMPACT
<br />1. ldenti fy and describe damages wh ich constitute a health end/or safety hazard to the general publ ic.
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<br />2, PIlpul_ _y .ffected din!Ctly or Indirectly by "'0 loa of pObIlIHI'"nl""'i>r~,
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<br />3. WhiM economic activities are adverselv affected by the toss of public f8ciUtles or damages?
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<br />B. RESPONSE CAPASI UTY: Can the applicant respond and recover from the damages quickly and without degradation of public services? Describe.
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<br />C. IMPACT ON PUBLIC SERVICES IF DECLARATION IS NOT MADE: e.g.. Deferral of pennanent repairs. impact on ongoing services and capitel
<br />improvements. etc. Describe.
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<br />NAME OF INSPECTOR
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<br />AGENCY
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<br />PHONE NO.
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<br />FEMA Form ~. JAN 84
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