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DocuSign Envelope ID:C6DC9C4F-C47A-4FD4-963D-64FC40BF7A2F <br /> 1.VAX It ii ..,,...v�,u�lA EMERGENCY MANAGEMENT <br /> FFY 2018 EMERGENCY MANAGEMENT PERFORMANCE GRANT <br /> (EMPG) <br /> APPLICATION <br /> Submission Deadline: February 7,2018 <br /> INSTRUCTIONS FOR COMPLETING EM FORM 66 <br /> A. Applicant Information <br /> • EM Agency Name - Type or print the official legal title of your Emergency Management <br /> (EM)agency. <br /> • Street Address, City, ZIP+4 - Type or print the street address, city, and nine digit zip <br /> code. <br /> • D-U-N-S Number - Type or print the unique nine-digit identification number for your <br /> county's agency. NOTE: Your financial personnel should be able to provide you with this <br /> number. <br /> • EIN/Tax ID Number- Type or print the unique nine-digit identification number for your <br /> county's agency. NOTE: Your financial personnel should be able to provide you with this <br /> number. <br /> • SAM Registered -Each applicant must be registered in the Federal System for Award <br /> Management(SAM)annually in order to be eligible to receive EMPG monies. The URL <br /> is https://www.sam.gov/. <br /> • Expiration Date- What is the expiration date for your SAM account? <br /> B. Applicant Point of Contact Information - Type or print the name and contact information for <br /> the person responsible for the day to day management of the grant once awarded. <br /> C. County EM Program Manager Contact Information - Type or print the name of the county <br /> Emergency Management Program Manager. NOTE: Must be the same title on the Position <br /> Description and Organization Chart. <br /> D. Finance Manaizer- Type or print the name of the county Financial Manager. NOTE: Must be the <br /> same title on the Position Description and Organization Chart. <br /> E. MOA Signatory Information - Type or print the name and contact information for the person <br /> that has signatory authority to accept the grant award on behalf of the municipality. <br /> F. Project Information <br /> • Anticipated Local EM total budget-Type or print the budget allocated by the county for <br /> the EM program <br /> • Pre-Award Cost Request- If you would like request pre-award cost please enter the <br /> amount and attach an explanation of what expenses the request will cover. <br /> • Time % - EM Program Manager will type or print the percentage of time the Program <br /> Manager devotes to Emergency Management program activities (e.g. 50%, 60%,90%, <br /> etc.). <br /> • Current Salary-Type or print the current annual salary for EM Program Manager. <br /> (Round to the nearest dollar). <br /> EMPG Application Form 66 (Rev. 01/18) Page 1 of 8 <br />