California Governor’s Office of Emergency Services - Notitice of Interest Application
HAZARD MITIGATION GRANT PROGRAM
NOTICE OF INTEREST
Control No:
All fields must be completed with valid input
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1. Disaster #:
2. Name of Person Completing NOI:
3. NOI Instructions have been received and read:

4. Federal Information Processing Number (FIPS #): nnn-nnnnn
5. Data Universal Numbering System (DUNS #): nnnnnnnnn

6. Applicant Name:
7. Applicant Address:
City: State:CaliforniaZip Code:
Project Location:

8. Applicant Type:
EIN (For Private Non-Profits):
9. Legislative Districts:
ApplicantProject Site
       State Assembly:
       State Senate:
       U.S. Congressional District:

10. Authorized Applicant Agent:
First Name:    Last Name: Salutation:
Title:
Address:
City:    State:CaliforniaZip Code:
Phone: - - Ext:
Fax #: - -
EMail Address:

11. Project Manager/Working Contact:
First Name:    Last Name: Salutation:
Title:
Address:
City:    State:CaliforniaZip Code:
Phone: - - Ext:
Fax #: - -
EMail Address:

12. Project Manager/Working Contact (Alternate):
First Name:    Last Name: Salutation:
Title:
Address:
City:    State:CaliforniaZip Code:
Phone: - - Ext:
Fax #: - -
EMail Address:

13. ApplicationType:

14 Hazard Type:

15. Project Type:
Explain if Miscellaneous/Other is selected.

16. Activity Title/Name:

17. Population (Planning Activities Only):

18. Activity Location:
Latitude & Longitude E.g,34.324862 -120.345677

19. Describe the problem to be mitigated:

20. Describe the scope of work:

21. Performance Period:
22. Duplicate Programs:

Is this activity eligible for funding from another federal program such as the NRCS Emergency Watershed Protection Act, FEMA Public Assistance Program,
and the US Department of Agriculture/Department of the Interior Healthy Forest Restoration Act of 2002?



If yes, identify the program and the Disaster Survey Report, Project Worksheet, or application number(s).



23. Activity Costs:
       Federal Requested Share:$
       Applicant Match:$
       Total Activity Cost:$
       Source of 25% non-federal match:

24. LHMP Approval Date:

25. Local Hazard Mitigation Plan:
Provide a narrative that identifies how the proposed project activity is in conformance with your FEMA-approved Local Hazard Mitigation Plan (LHMP). Any references to the LHMP must include the page number and/or section.

Electronic Notification of NOI Status, Workshops, and Application Updates
The Hazard Mitigation Grant Program will provide immediate notification of your NOI status following our review. Please provide us with the contact information for 1 of your staff.
(If the contact is the same as entered above, please reenter the information below. This person will receive information about workshops and updates regarding the application process.)

Contact Person:Name: (Last, First)


Email Address:

Created on 12/07/2019 01:07:52 PM

NOTE: Please print this form before clicking the Submit NOI button below.
You will not be able to print the NOI once you have pressed the Submit NOI button.
You will receive a project control number once you click on submit button. Please retain this number and include it in any correspondence with Cal OES regarding your project.



(FYI: Pressing the Submit NOI button will save and submit your NOI to the Governor's Office of Emergency Services for Approval. Please ensure that you have filled out this form with as much detail as possible.)