Hazard Mitigation Grant Program Application Template

June 2022 - Page 1

Community Safe Room: Application

*The following information is intended for guidance only and is not a request for information. The following template

is only intended to help the reader understand the FEMA Hazard Mitigation Grant Program (HMGP) application

process.

A. Applicant/Subapplicant Information

1. Applicant/Subapplicant Legal Name:

2. Organizational Unit:

3. Project Title:

4. Applicant/Subapplicant Type: Local Government State Government 

Private Nonprofit Other: ____________________

(attach copy of Form 501c3)

Territory/Commonwealth 

 Federally Recognized Tribal Government

5. Proposed Project Total Cost: $ 

Federal Share ( %): $ Local Share ( %): $ 

6. Certifications

The undersigned assures fulfillment of all requirements of the Hazard Mitigation Grant Program, as contained in the 

program guidelines, and affirms that all information contained herein is true and correct to the best of my 

knowledge. The governing body of the applicant duly authorized the document, and hereby applies for the 

assistance documented in this application. The applicant recognizes that the project may proceed ONLY AFTER 

FEMA APPROVAL is granted. 

Typed Name of Authorized 

Representative/Applicant Agent

Title Phone Number

Signature of Authorized 

SAMPLE

Representative/Applicant Agent Date Signed
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7. Does your community or Tribe have a current FEMA approved hazard mitigation plan? 

Yes No

Title of the Plan: Adoption date: 

Location of proposed project in mitigation plan strategies: Page Section 

Does the project align with the State/Territorial/Tribal Hazard Mitigation Plan? 

Yes Page Section 

8. Does the community participate in the National Flood Insurance Program (NFIP)? Yes No 

9. Tax ID Number: FIPS Code (5 digits): 

Community ID Number (6 digits): DUNS Number (9 characters): 

10.U.S. Congressional District: 

11.State Legislative District: 

12.Primary Point of Contact 

If the project is awarded, person responsible for coordinating the implementation of this grant throughout the 

application process.

First Name: Last Name: 

Title: 

Address Line 1: 

Address Line 2: 

City: State: Zip: 

Office Phone: Mobile Phone: Fax Number: 

Email Address: 

13.Alternate Point of Contact 

First Name: Last Name: 

Title: 

Address Line 1: 

Address Line 2: 

City: State: Zip: 

Office Phone: Mobile Phone: Fax Number: 

Email Address: 

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14.Authorized Applicant/Subapplicant Agent 

MUST be the chief executive officer, mayor, or person of comparable status who is authorized to sign contracts, 

authorize funding allocations or payments, etc.

First Name: Last Name: 

Title: 

Address Line 1: 

Address Line 2: 

City: State: Zip: 

Office Phone: Mobile Phone: Fax Number: 

Email Address: 

B. Project Narrative and Scope of Work 

1. The proposes to construct a multi-use/single-use community safe room at the 

following locations: 

Enter location(s) (address, latitude/longitude to six decimal places of approximate location where safe room will 

be installed). Specify multi-use or single-use for each.

 

 

2. For each proposed safe room, identify the following: ground level (above or below), prefabricated or site 

constructed, stand-alone or internal, and location of access routes and staging areas. 

Identify the four criteria listed above for each proposed location.

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3. For each proposed safe room, indicate if the safe room will be a retrofit of an existing structure or new 

construction. For each retrofit safe room, describe the existing conditions of the structure and provide photos of 

structure and any adjacent structures. Provide a brief description of the site and explain why this particular site 

was chosen.

Describe the existing condition of the structure.

4. For each proposed safe room, identify the protected population, the maximum number of occupants, and the

gross and useable area of the safe room. State whether the safe room will be open to the public or designed to 

protect evacuees originating from a specific building or campus of buildings.

Describe the occupant population, maximum number of occupants and the public access status.

5. Briefly describe the most recent disaster event that demonstrates the need for a community safe room. Please 

include the federal disaster declaration number, if applicable/available.

Describe the most recent disaster event.

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C. Safe Room Purpose(s)

Extreme wind (combined tornado and hurricane) community safe room

Tornado community safe room

Hurricane community safe room

Safe room will allow for accessibility of persons with disabilities (required for public safe rooms). Yes No

D. Alternatives Considered 

Include details for one no-action alternative and consequences and at least one alternative action. Include a 

description of why the selected project was chosen.

No action alternative and resulting consequences, why this alternative was not selected.

Alternative action considered but not selected, and why.

E. Impacted Population and Travel Limitations 

If a hurricane safe room, the impacted population is (select one from below):

Category 1 (first responders, critical/essential services personnel, and facility occupants)

Category 2 (individuals that cannot evacuate)

Category 3 (islands, states, or territories)

Category 4 (people living in an excavation zone)

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Explain why the selected project was the best alternative.

Describe the rationale for including each group designated as a disproportionately impacted population.

The impacted population will reach the safe room by:

Describe how the proposed occupants will get to the safe room. Indicate travel time and distance. Or attach a 

map with the travel route.

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Proposed occupants will know how to locate the safe room because:

Describe the warnings, capabilities, logistics and operations components that will be in place.

F. Access Roads

1. Are safe room occupants expected to drive to the safe room in the event of a tornado? Yes No

If yes, answer the below questions in this application section:

Is a traffic study available? Yes No

Obstruction on the path to the safe room: _____of cars traveling in (time period) on side streets.

Are there highways or railroad crossings along the primary travel path to the safe room? Yes No

2. Will access roads and parking lots be installed to service the safe room? Yes No

Provide details in the box below. If it was performed, attached the traffic study as part of the subapplication.

Describe access roads and any site/construction obstructions that would affect access to the community safe 

room. Describe available parking areas/lots to be used by safe room occupants. 

G. Period of Protection

The impacted population will be provided ______ hours of protection by the shelter.

 For tornado community safe rooms, the minimum period of protection is 2 hours.

 For hurricane community safe rooms, the minimum period of protection is 24 hours.

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H. Wind Speed Zone and Internal Pressure Coefficient

The wind speed zone for the proposed safe room is:

130 mph 160 mph 200 mph 250 mph 

Design wind speed: _____ mph

Internal Pressure Coefficient (GCpi): ______________ (Value)

I. Proposed Occupancy and Required Usable Area

1. Indicate the safe room occupancy: _______ people

2. Is the safe room occupancy greater than or equal to 50 occupants? Yes No

3. Will a peer review be performed? (required for community safe rooms designed for 50 or more occupants)

Yes No

Tornado Safe Room

Safe Room 

Occupant Type

Minimum Required 

Usable Floor Area per 

Safe Room Occupant 

(square feet) 

Proposed Persons 

Protected 

Total Square Footage 

Needed per Type 

(multiply column 2 x 3)

Standing or seated 5 

Wheelchair user (safe room design 

should assume 1 per every 200 

persons protected or portion thereof)

10

Bedridden 30

Required Usable Area 

Hurricane Safe Room

Safe Room 

Occupant Type

Minimum Required 

Usable Floor Area per 

Safe Room Occupant 

(square feet)

Proposed Persons 

Protected 

Total Square Footage 

Needed per Type 

(multiply column 2 x 3)

Standing or seated 20

Wheelchair user (safe room design 

should assume 1 per every 200 

persons protected or portion thereof)

20

Bedridden 40

Required Usable Area 

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If community safe room is a hurricane safe room, the jurisdiction will also ensure the safe room is operated in a 

manner consistent with all local and state emergency evacuation plans and requirements.

Describe how the hurricane community safe room meets all local and state emergency evacuation 

plans/requirements. 

J. Usable Floor Area

Safe Room gross area: ______ square feet

Area of ineligible floor space: ______ square feet

Method 1: Remove ineligible floor area from gross area, then reduce remaining floor area by using a multiplier 

based on type of furnishings.

Select one item from those available below that best describe the usable floor area in the proposed/designed 

community safe room. Do not include areas for bathrooms, mechanical, electrical or storage rooms.

Concentrated furnishings or fixed seating – reduce 50% (multiplier = 0.5)

Unconcentrated furnishings and without fixed seating – reduce 35% (multiplier = 0.65)

Open plan furnishings and without fixed seating – reduce 15% (multiplier = 0.85)

Total gross square footage ______ - Area of ineligible floor space ______ = _______ square feet

Reduced area ______ x “multiplier” ______ = ______ square feet of allowable usable area

Method 2: Subtract unusable area from the gross area, then apply a 15% reduction as best practice for egress 

adjustment.

Indicate the total area of obstructions in the safe room: ______ square feet

Total gross square footage ______ - Area of ineligible floor space ______ = _______ square feet

Reduced area ______ - Area of obstructions ______ = _______ square feet

Unobstructed area ______ x 0.85 egress adjustment = ______ square feet of allowable usable area

K. Feasibility and Effectiveness

1. Indicate the current level of design for the safe room. Conceptual Detailed

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2. Describe the design standards and editions of the standards used for the design of the safe room. 

List design standards and editions used in safe room design. Provide a floor plan, if avaiable.

3. Compliance requirement: 

 By checking this box, applicant/subapplicant acknowledges that upon project completion, a certification 

letter (to be included in the closeout documentation) must indicate that the safe room, and all items that 

contribute to the operation of the safe room, were constructed to meet or exceed FEMA P-36 requirements. 

Provide statement that upon completion, a certification letter will be provided.

L. Opening Protection

Indicate the design standards, including wind-borne debris missile-impact criteria, that the opening protection 

will meet.

Describe opening protection systems, testing standards, and performance criteria.

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M.Emergency Power System

Provide details about the emergency power system. Indicate type, design duration, fuel type (if applicable), level 

of protection and location.

Describe the emergency power system for the safe room.

N. Utilities

Will new above ground or below ground utilities be installed? Yes No

If yes, Utilities will be placed above ground 

 Utilities will be placed below ground 

Provide additional details necessary for utility construction.

O. Sanitation Facilities

The community safe room must include sanitation facilities, in accordance with ICC 500 Table 702.3 for tornado 

safe rooms or Table 703.3 for hurricane safe rooms. Indicate the number of water closets and lavatories 

provided in the safe room.

Number of water closets: ______

Number of lavatories: ______

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P. Potable Water Storage

ICC 500 Section 703.4 specifies requirements of potable water supply and wastewater storage for hurricane 

storm shelters designed to accommodate more than 50 occupants.

Describe the potable water storage system (e.g., type, size). Describe how the water supply will be distributed 

to the safe room.

Q. Environmental Planning and Historic Preservation Considerations

1. Has the public been notified or provided input? If so, provide dates and method of outreach. If not, describe any 

planned public engagement activities for the project.

Explain public outreach input or planned activities.

2. Describe any agency coordination and permits obtained for the project. Provide copies of these, if applicable.

Describe. If not applicable, write N/A.

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3. Describe any studies that have been conducted for the project. Provide copies of these, if applicable.

Describe. If not applicable, write N/A.

4. Describe the project activities in the floodplain, if applicable.

Describe. If not applicable, write N/A.

5. Describe any surface waters in or near the project area (e.g., ponds, lakes, rivers, streams, wetlands, other 

waterbodies). Describe any measures that would be used to avoid waterbodies or avoid impacting water (e.g., 

setbacks, silt fence). 

Describe. If not applicable, write N/A.

6. Describe any known hazardous or contaminated materials at the project site including underground tanks. 

Describe how the underground tanks (e.g., fuel, septic) would be removed or decommissioned in place. If the 

project requires the use of hazardous materials (including herbicides), describe their use and best management 

practices to minimize environmental exposure.

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Describe. If not applicable, write N/A.

7. Does your project involve the use of imported fill? Yes No

If yes, describe the type and source of the fill material. If not applicable, write N/A.

8. If the project would remove vegetation for any reason, describe the type and amount or area of vegetation (e.g., 

two oak trees, one-quarter acre of turf grass). Describe how vegetation would be removed, if applicable (e.g., 

root ball removal, flush cut, dug up, chemical weed killer). If using herbicides, describe best management 

practices for their use. Estimate during which season(s) or months vegetation removal would occur. Will the 

project replant or restore vegetation when construction is complete? Describe the plants that would be installed 

and the equipment and methods to be used. Would any special techniques be used to ensure survival of the 

plants/ seeds (e.g., mulch, irrigation, protective fencing)?

Describe. If not applicable, write N/A.

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9. List any best management practices that would be used during project construction. 

Describe. If not applicable, write N/A.

10. Describe the physical characteristics of ground disturbance.

Describe. 

11. What are the approximate dimensions for ground disturbance for the safe room?

 Value Unit of Measure 

Width

Length

Depth

Volume of Ground Disturbance (L x W x D) 

12. What are the approximate dimensions for ground disturbance for any new utilities?

Direction Value Unit of Measure 

Width

Length

Depth

Volume of Ground Disturbance (L x W x D) 

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13. What are the approximate dimensions for ground disturbance for any new roads or driveways to service the safe 

room? 

Direction Value Unit of Measure 

Width

Length

Depth

Volume of Ground Disturbance (L x W x D) 

14. Total Ground Disturbance.

Category Calculated Volume Unit of Measure 

Safe Room

Utilities 

Roads/Driveways 

Volume of Ground Disturbance 

(Safe Room + Utilities + Roads/Driveways) 

R. Operations and Maintenance Plan

Jurisdiction will provide a final Operations and Maintenance (O&M) Plan prior to project closeout per HMA 

Guidance Addendum C.5.1, and:

Attached draft O&M Plan

Descriptive statement of an O&M Plan, including assurance that the O&M Plan will be developed and 

completed before project closeout

S. Estimated Work Schedule

Enter the estimated duration for each listed activity. Although the activities listed may not be necessarily 

sequential, the total grant timeline cannot exceed 36 months.

Task/Activity Start Month End Month Timeline

 

 

 

 

 

 

 

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Task/Activity Start Month End Month Timeline

 

 

 

 Total timeline (must not exceed 36 months): 

T. Budget Estimating

1. Costing Methodology

The method(s) used to estimate project costs is (provide backup documentation for method(s) used):

Estimates obtained from construction contractors and similar vendors

Historical data from previous projects/activities with an inflation factor, as needed

Public Works personnel or other qualified staff from local jurisdiction provided estimates based on 

experience or field associate experience

RS Means, Marshall & Swift or other national cost estimating service

Other, please explain.

Enter explanations, as needed.

2. Cost Estimate

The Applicant/Subapplicant must ensure that all project costs are reasonable and necessary for the activity 

according to Title 2 Code of Federal Regulations Part 200 Uniform Administrative Requirements, Cost Principles, 

and Audit Requirements for Federal Awards. Budgets should include various cost-item categories, such as 

personnel (labor) and fringe benefits, travel, equipment, supplies (materials), contractual, construction, preaward costs, contingencies, program income, and indirect costs. 

The costs included in this

SAMPLE

project are below, as applicable, and detailed in the justification box below.
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Line Item Unit Quantity Unit Measure Unit Cost Line-Item Cost 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

$ $ 

Total Project Cost $ 

Federal Share (______%) $ 

Nonfederal Share (______%) $ 

3. Budget Narrative

Provide a budget narrative with explanations, justifications, and line-item details of the project costs noted in the 

table above. Attach an additional sheet if necessary.

Define cost line items, provide information of how they were estimated, and disclose any assumptions to justify 

the values used.

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U. Nonfederal Funding Share (25% of Total Project Costs) 

List all sources and amounts used in the nonfederal share, including all in-kind services. In-kind services may 

not exceed the 25% nonfederal share. Attach letters of funding commitment for each source.

Source Name of Source Agency Type of Funding Amount Commitment 

Letter Attached 

$ Yes No

$ Yes No

$ Yes No

V. Cost-Effectiveness

1. Benefit-Cost Analysis (BCA) Toolkit: Cost-effectiveness for this project was calculated using the FEMA-approved 

BCA software. The benefit-cost ratio was determined to be _______.

An export of the BCA tool and pdf of the BCA is to be included with this application as required documentation. It 

is recommended that the application includes a BCA narrative describing the methodology, assumptions, and 

justifications for all inputs to the subapplication documentation.

2. If the FEMA standard project useful life (PUL) was not used, was documentation provided to justify usage of a 

different value? (The PUL value cannot be higher than the highest acceptable limits as indicated in the PUL table 

in the BCA Toolkit Help Menu.) 

Yes No, the FEMA standard PUL was used.

3. Maintenance Costs: Maintenance costs for the safe room should include maintenance for the safe room and all 

items that contribute to the operation of the safe room.

Attach an assurance letter from the signature authority that indicates the annual maintenance costs, what 

position or department will be responsible for maintenance, and how often it will be performed. The 

maintenance cost should cover the necessary maintenance for the retrofit to remain functional for the entire 

PUL. 

The jurisdiction will be responsible for O&M of the resulting safe room, valued at $_______ per year.

4. Wind Speeds: For hurricane safe rooms, describe how the wind speeds were determined. Provide supporting 

document, such as information from the ATC Hazards website (

SAMPLE

https://hazards.atcouncil.org/).
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Explain how wind speeds were determined.

5. Predominant Structure Type(s): Describe how the structure type(s) and percentage(s) of total occupancy coming 

from each structure type were determined.

Explain how type and percentages were determined.

W. Required Documentation Attached 

Site Photos – Include photos of the sites. If a warning system(s) is/are provided, identify where equipment or 

structures will be installed or the buildings/structure(s) where siren(s) will be affixed.

Structure photographs including ingress and egress from the safe room

Project Site Map – Provide a plan view of the site that clearly identifies the project boundaries, components, 

construction staging and storage area, and any relevant feature.

FIRMette with project location(s) clearly marked. FIRMettes can be accessed in the FEMA Flood Map Service 

Center. 

Documentation to support determination of 100-year (0.1%) or 500-year (0.2%) flood elevations (if proposed 

safe room will be located in a flood prone area).

Impacted Population and Travel Limitations - Provide supporting documentation for the number of safe room 

occupants.

Maps with travel routes to the safe room - Indicate travel path to the safe room. 

Access Roads - If applicable, provide the traffic study.

Usable Floor Area - Provide usable floor area calculation.

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 Floor plan, if available.

Compliance documentation with any applicable local planning, zoning, and other applicable codes. 

Draft O&M plan or descriptive statement of the O&M plan, including assurance that the O&M plan will be 

developed and completed before project closeout.

 Consultation Documentation (HMA Guidance Addendum, A.6.6)

 USACE – the jurisdiction must demonstrate that it has consulted with USACE regarding each subject 

property’s potential use for the construction of a flood levee system (including berms, floodwalls, and dikes). 

 Department of Transportation – the jurisdiction must demonstrate that it has consulted with the relevant 

state Department of Transportation to ensure that plans do not contain any improvements or enhancements

to federal aid systems or other state transportation projects that would affect the proposed project area 

under consideration.

 Other Federal Agency – the jurisdiction must demonstrate that it has consulted with other federal agencies 

as appropriate, regarding other program requirements and/or activities, and have identified the relationship 

between them to FEMA mitigation grant activities and funding. 

Environmental Planning and Historic Preservation documents:

 Public outreach documentation

 Obtained permits

 Documents of coordination with regulatory agencies

 Environmental and historic resource studies

 Maps that include known surface water and vegetation removal locations

 Photographs of structure(s)

 Other documents, if applicable 

State Historic Preservation Office Consultation 

State Historic Preservation Office response needed if: 

(1) structure is or will be 45 years or older at the time of FEMA application review

(2) new ground is being disturbed 

(3) project is located in a Historic District.

This applies to all properties including alternates.

BCA export and pdf

BCA narrative (recommended)

Fund commitment letter(s) that list(s) the sources and amounts used in the nonfederal share requirement, 

including all in-kind services.

Completed and signed assurances (FEMA Form 112-0-3C or 20-16c (Certifications Regarding Lobbying; 

Debarment, Suspension and Other Responsibility Matters; and Drug-Free Workplace Requirements), and SF-LLL 

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(Disclosure of Lobbying Programs) if applicable) 

 FEMA Form 112-0-3C will also be accepted in place of 20-16c.

SF-424 (Application for Federal Assistance) (optional for subapplications in HMGP) 

SF-424d (Construction Programs) (if required by the Grantee; contact applicant agency)

SF-424c (Budget Information for Construction Programs) (if required by the Grantee; contact applicant agency)

Detailed budget with budget narrative and documentation to support all costs, including:

 Estimates or quotes from construction contractors and similar vendors

 Historical data from previous projects/activities

 Estimates from public works personnel or personnel with experience on similar projects

 Copies of information from national cost estimating services or guides

Documentation to support management costs, including job titles, number of hours, 

and price per hour

Designated Authorized Agent documentation: designating authority for the signatory to sign contracts, authorize 

funding allocations or payments, or apply for grant funding that is signed by the ruling body of the applicant. 

Detailed schedules (if necessary) to support scope of work

Documentation from a qualified professional to support completion of peer review, if applicable and available. 

Verification that a peer review (if applicable) was conducted must be provided at closeout.

Documentation to support predominant structure type(s) and corresponding percentages of occupancy

Supporting data for wind speeds (hurricane safe rooms), such as information from the ATC Hazards website

Design Certification Statement (Provide statement that, upon project completion, a licensed architect or 

professional engineer will confirm that the safe room and all items that contribute to the operation of the safe room 

were constructed to meet or exceed FEMA P-361.

Other comments, information, or explanation:

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Enter explanations, justifications, and other details, as needed.

SAMPLE