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Public Assistance Grant Agreement Page 21 of 21 Kittitas County, D20-189 <br />Attachment 3 <br />PROJECT WORKSHEET SAMPLE <br />U.S. DEPARTMENT OF HOMELAND SECURITY <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />PROJECT WORKSHEET <br />O.M.B. 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 financial <br />resources expended by persons to generate, maintain, disclose, or to provide information to us. You may send comments <br />regarding the accuracy of the burden estimate and or any aspect of the collection, including suggestions for reducing the burden <br />to: Information Collections Management, U. S. Department of Homeland Security, Federal Emergency Management Agency, 500 <br />C Street, SW, Washington, DC 20472, Paperwork Reduction Project (OMB Control Number 1660-0017). You are not required to <br />respond to this collection of information unless a valid OMB number appears in the upper right corner 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 <br />E <br />M <br />A <br />- <br />- <br />F <br />M <br />D <br />R <br />- <br />R <br /> <br />DAMAGED FACILITY WORK COMPLETE AS OF: <br /> : % <br />SUBRECIPIENT COUNTY <br />LOCATION LATITUDE 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 <br />T <br />E <br />M <br />CODE NARRATIVE QUANTITY/UNIT UNIT PRICE COST <br /> / <br /> / <br /> / <br /> / <br /> / <br /> / <br /> / <br /> / <br /> / <br /> TOTAL COST <br />PREPARED BY TITLE SIGNATURE <br />SUBRECIPIENT REP. TITLE SIGNATURE <br />FEMA Form 90-91, FEB 06 REPLACES ALL PREVIOUS EDITIONS.