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Attachment #3 <br />PROJECT WORKSHEET SAMPLE <br />U.S. DEPARTMENT OF HOMELAND SECURITY <br />FEDERAL RMERCENCY MANAGEMENT AGENCY <br />PROJECT WORKSHEET <br />0. M.3. No. 1660-0017 <br />PAPERWORK BURDEN DISCLOSURE NOTICE <br />Public reporting burden for this form is estimated to average 90 .minutes per response. Burden means the time, effort and fir ancial <br />resources expended by persons to generate, mainiain, disclose, or to provide information to us. You may send comments <br />regarding the accuracy of the burder. estimate ar:d or any aspect of the c6lection, including suggestions for reducing the burden <br />to: Information Collect'.ons Maragemert, U. S. Departmentcf Homeland Security, Federal Emergency Management Agency, 5u0 <br />C Street, SW, Washington, DC 20472, Papenv►ork Reduction Project (OMB Ccrtrol Number "660-0017). You are not required t3 <br />respond to this co!lecticr of information unless a valid OMB number appears in the upper right comer of this form. NOTE: Do not <br />send your completed form to this address. <br />DISASTER PROJECT NO. PA ID NO. DATE CATEGORY <br />F _ R <br />DAMAGED FACILITY <br />WORK COMPLETE AS OF: <br />SUBRECIPIENT <br />COUNTY <br />LOCATION <br />LATITUDE <br />LONGITUDE <br />DAMAGE DESCRIPTION AND DIMENSIONS <br />SCOPE OF WORK <br />Does the Scope of Work change the pre -disaster conditions at the site? ❑ Yes ❑ No <br />Special Considerations issues included? ❑ Yes ❑ No Hazard Mitigation proposal included?❑ Yes ❑ No <br />Is there insurance coverage on this facility? ❑ Yes ❑ No <br />PROJECT COST <br />I CODE NARRATIVE QUANTITY[UNIT UNIT PRICE COST <br />1 <br />1 <br />1 <br />l <br />TOTAL COST <br />[PREPARED <br />HY <br />T TLE <br />SIGNATUREJBRECIPIENT <br />REP_ <br />TITLE <br />SIGNATURE <br />rr—mrr rQrm 5u—a 1, -Lts uo KhPLA0E8 ALL PREVIOUS EDITIONS. <br />Public Ass;stance Grant Agreement Page 21 of 21 Kittitas County, D16-619 <br />