Fillable NOI Form - Part B STATE OF ARIZONA (Arizona)

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NOI Form - Part B STATE OF ARIZONA (Arizona)

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Page 1 of 7
THIS SECTION FOR STATE USE ONLY
Received By:
Date Received:
Revision Requested:
Point of Contact:
State Hazard Mitigation Officer
Office: 602-464-6349
Email: Lucrecia.Hernandez@azdema.gov
Hazard Mitigation Assistance (HMA)
Notice Of Intent (NOI)
STATE OF ARIZONA
DEPARTMENT OF EMERGENCY AND MILITARY AFFAIRS
NOTE: NOI
Cover Sheet - Part A (with original ink signature) must be scanned and emailed as a separate file.
Remainder
of NOI form (Part B) must be saved and submitted in original .pdf format (not scanned). Any
additional supporting information may be submitted as separate additional electronic files.
1. Legal Name:
Organizational Unit:
3.
5.
$
$
Total Proposed Project Cost:
Federal Share (up to 75%):
Non-Federal Match (at least 25%):
$
Final
Version:
NOTE: "NOI Form - Part B" will not be accepted without an accompanying
"NOI Cover Sheet - Part A" correctly filled out and submitted.
NOI Form - Part B
Multiple Submissions:
Project Title:
%
%
Federal Share Percentage:
Non-Federal Percentage:
2.
This NOI is for a (check one):
4.
Project
Plan
5% initiative (HMGP only)
Do you qualify as an Impoverished Community?
6.
More detailed information is provided in the HMA Guidance, Part III, C, and Cost Sharing
,
available at http://www.fema.gov/media-library/assets/documents/103279.
Yes
No
Unsure
v. 12-6-17
Page 2 of 7
CONTACT INFORMATION
7.
The Primary Point of Contact is the person responsible for coordinating the implementation of this proposal, answering
questions and/or making revisions.
Ms. Mr. Mrs.
First Name:
Last Name:
Title: Organization:
Street Address:
City: State: Zip Code:
Telephone: Fax: Mobile: E-mail Address:
The Alternate Point of Contact is the person that can address questions or concerns in the Primary Point of Contact’s
absence.
Ms.
Mr. Mrs. First Name:
Last Name:
Title: Organization:
Street Address:
City: State: Zip Code:
Telephone: Fax: Mobile: E-mail Address:
9.
Applicant Agent (If different from Primary or Alternate Point of Contact):
Ms.
Mr. Mrs. First Name:
Last Name:
Title: Organization:
Street Address:
City: State: Zip Code:
Telephone: Fax: Mobile: E-mail Address:
Primary Point of Contact: Please check this box if the Primary Point of Contact is also the Applicant Agent
8.
Alternate Point of Contact:
Please check this box if the Alternate Point of Contact is also the Applicant Agent
The Applicant Agent is the person that is the official and legal recipient of potential funding on the behalf of an entity.
v. 12-6-17
Page 3 of 7
10. Provide the Latitude and Longitude for:
Latitude: Longitude:
Project Location
(If project is for a large area,
provide coordinates for each
"corner" of the project's area.)
Latitude: Longitude:
SITUATION DESCRIPTION
11.
Describe the problem to be solved. If applicable, include past occurences and how often they occur.
12. Population Affected
Provide the number of each type of structure (listed below) in the project area. Include all structures in project area.
residential properties
b
u
s
i
n
e
s
s
es
/
c
o
m
m
e
rcial properties
public buildings
schools / houses of worship
critical facilities/infrastructure
v. 12-6-17
Latitude:
Longitude:
Latitude: Longitude:
SCOPE OF WORK
13.
Project Description
Describe, in detail, the proposed project. Explain how the proposed project will solve the problem(s) and
provide the level(s) of protection. Include a description of the desired outcome and methodology of the mitigation
activity in terms of mitigation objectives to be achieved.
14.
Alternative Solutions
List the titles of three (3) Alternative Solutions for this project (one of which may be "No Alternative").
a.
b.
c.
Page 4 of 7
v. 12-6-17
Page 5 of 7
Budget
In this section, provide the details of all costs of the project. For estimates, reasonable projections
are essential.
a.
Estimated Cost for Acquisition
b. Estimated Cost for Demolition
c.
Estimated Force Account Labor Costs
d.
Estimated Force Account Equipment Costs
g.
Estimated Project Management Costs
Total Estimated Cos
t
15.
h. Estimated Contract Costs
i. Estimated Permits/Licensing Costs
j. Estimated Legal Costs
k. Estimated Other Costs -
l.
Estimated Other Costs -
m.
Estimated Other Costs -
16. Non-Federal Funding Share (25% of Total Cost)
List all sources and amounts utilized in the non-federal share including all in-kind services. In-kind services may not
exceed the 25% non-federal share. If any portion of the non-Federal share will come from non-applicant sources
(donated services, private donation, etc.), attach letters of funding commitment for each non-applicant source.
Source
Name of Source Agency
Type Funding Amount
Commitment
Letter
Attached
?
$
$
$
$
$
Source = Local, Private Non-Profit, Other
Source Agency
= Specific entity providing match
Type Funding = A
dministration, Cash, Consulting Fees, Engineering Fees, Equipment Operation/Rental, Labor, Supplies, Other
$
$
$
$
$
$
$
$
$
$
$
$
Enter the Benefit Cost benefits, cost, and ratio determined prior to application. If Benefit Cost Analysis was not required
or waived, place an “N/A” in the blanks, and provide explanation below (c.) for the exemption.
Was the BCA calculated using the most current FEMA BCA Toolkit version?
Yes
No
Benefit: $
Cost: $
Ratio:
N/A
b.
Benefit Cost Analysis (BCA)
17.
a.
A project must show a benefit-to-cost ratio of 1 or greater to be eligible for HMA grant funding. If the most current
FEMA BCA Toolkit version was not used, qualitatively describe why you think the benefits (damages or losses avoided)
to people, property, the environment, emergency services and/or critical infrastructure is great enough to justify the
project cost. Please explain why you believe that if calculated, your BCA would meet the minimum 1.0 requirement.
c.
v. 12-6-17
Page 6 of 7
19.
Maintenance
The following questions are to give assurance on the project’s maintenance over its useful life. Please answer each
question and give a brief explanation.
a.
b.
c.
Will the project require periodic maintenance? For how long?
If yes, who will provide the maintenance?
What
is the estimated cost of maintenance on an annual basis?
18. Timeline
Insert the proposed work schedule as tasks to accomplish the overall goal of the proposed activity, i.e., appraisals, title
search, closing, etc., and provide a description of the task’s purpose.The first and last entries are state requirements and
have already been entered.
Task 1:
DEMA Initial grant management and processing
Timeframe:
30 days
The initial period for setting up the grant managment process and contractual Applicant
Agreement.
The timeframe reflects up
to a
30
day
period.
Task 2:
Timeframe:
Task 3:
Timeframe:
Task 4:
Timeframe:
Task 5:
Timeframe:
Task 6:
Timeframe:
Task 7:
Timeframe:
Task 8:
State Compliance Review and Closeout
Timeframe:
60 days
Financial and project reconciliation with local, state, and federal concurrence.
Total Timeframe (must not exceed 1,095 days, 36 months, or 3 years)
Timeframe:
Yes
No
$
Property Owner
Street Address
Policy Number
Repetive Loss
Property?
20. NFIP Properties
Please list any NFIP properties in the project area.
Severe Repetive
Loss Property?
a.
b.
If there are additional NFIP properties not listed above, please note the number of additional properties.
v. 12-6-17
Note - For PDM and FMA applications, the "DEMA Initial grant management and processing"
time does NOT include FEMA review period for eligibility or Enviromental/Historical Review
compliance. Please estimate and include the FEMA review time as Task 2.
FEMA review and award period for PDM and FMA applications
Depending upon complexity, this period may be months and can exceed a year.
Page 7 of 7
PROJECT OVERVIEW
21.
Yes No
Does your community have a current FEMA approved multi-hazard mitigation plan?
Expires on:
22. Is the community a member of good standing with the National Flood Insurance Program?
23. Has the community adopted the IBC nationally recognized building code?
Name of plan.
24. Does your community have a Community Rating System (CRS)?
Yes No
Yes No
25. Is your community a FireWise Community?
26. Is your community a Storm Ready Community?
27. Does your community have a Community Wildfire Protection Plan?
33. Has the applicant successfully implemented previous mitigation grants?
Yes No
Yes No
Yes No
Yes No
28. Does the project reduce the needs for emergency services?
29. Does the project reduce threats to multiple communities?
30. Does the project reduce the risk to life safety?
32. Is the applicant willing to increase their "non-federal" match funding for this project?
31. Does the project reduce the risk to property damage?
36.
34. If the project is flood related, is the project involve a Repetitive Loss structure?
35. If the project is flood related, is the project involve a Severe Repetitive Loss structure?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
38. Enter any additional comments related to this project?
Are you submitting additional supporting documentation for this NOI? (Not required)?
Does the project involve significant Environmental, Historical or legal issues? If so, please list.
Yes No
37.
v. 12-6-17
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NOI Form - Part B STATE OF ARIZONA (Arizona)

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Completed 12 August 2020

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