FEDERAL EMERGENCY MANAGEMENT AGENCY REQUEST FOR FIRE SUPPRESSION ASSISTANCE				O.M.B. No. 3067-066 Expires July 31, 1994
PAPERWORK BURDEN DISCLOSURE NOTICE DISCLOSURE OF BURDEN - Public reporting burden for the collection of information entitled "Request for Fire Suppression Assistance" using FEMA Form 90-58 is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the forms. Send comments regarding the burden estimate or any aspect of the collection, including suggestions for reducing the burden, to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, S.W., Washington, D.C. 20472; and to the Office of Management and Budget, Paperwork Reduction Project (3067-0066), Washington, D.C. 20503.
1. STATE		2. DATE OF REQUEST	3. TIME OF REQUEST
4. NAME OF GOVERNOR OR AUTHORIZED REPRESENTATIVE MAKING AN OFFICIAL REQUEST			5. LOCATION
			6. TELEPHONE NUMBER
7. NAME OF STATE FORESTER (If different from 4.)			8. LOCATION
			9. TELEPHONE NUMBER
I. EXISTING CONDITIONS
10. EXISTANCE OF HIGH FIRE DANGER CONDITIONS	a. TEMPERATURE	b. RELATIVE HUMIDITY	c. DIRECTION AND VELOCITY OFWINDS
	d. PREVAILING WEATHER CONDITIONS AND PREDICTION FOR NEXT 24 HOURS
11. NUMBER OF WILD FIRES a. UNCONTROLLED__ ____ ACRES BURNED__ __			b. CONTROLLED__ __ ACRES BURNED___ __
12. EXTREME FIRE POTENTIAL CONDITIONS: a. STATE CLIMATE DIVISION INVOLVED__ ___________ b. WATCH ( ) WARNING ( )
13. ADDITIONAL REMARKS (Existing conditions)

FEMA Form 90-58, OCT 91 Page 1 of 4 pages

II. FIRE SITUATION
14. SITUATION REPORT (Provide a separate situation report for each uncontrolled fire or fires in a localized geographical area for which Federal assistance is requested; included under Item 14b. below).
a. TIME OF REPORT		b. NAME OF UNCONTROLLED FIRE					c. DATE STARTED
d. LOCATION OF UNCONTROLLED FIRE							e. COUNTY
f. DESCRIPTION OF UNCONTROLLED FIRE
g. ACRES BURNING (Forest)	(Grassland)					ESTIMATED COST TO SUPPRESS $
h. CASUALTIES	1. CIVILIAN LOSS OF LIFE__ _______ 2. FIRE FIGHTERS LOSS OF LIFE__ __				3. CIVILIAN INJURED___ ____________ 4. FIRE FIGHTERS INJURED__ _______
i. ESTIMATED VALUE OF PROPERTY DESTROYED TO DATE
(Forest) $			(Grassland) $	(Structures) $				(Other) $
j. MANPOWER AND EQUIPMENT COMMITTED 1. STATE				2. LOCAL
k. EXISTENCE OF OTHER FIRES NEARBY WHICH MAY RESULT IN A CONFLAGRATION
l. EXISTENCE OF OTHER FIRES NEARBY WHICH LIMITS THE COMMITMENT OF STATE FIRE FIGHTING RESOURCES
m. ADDITIONAL REMARKS (Fire situation)

Page 2 of 4 pages

III. CURRENT THREAT
15. THREAT TO LIFE (No. of persons endangered)	a. WERE PREPARATIONS MADE FOR EVACUATION? YES NO		b. NUMBER OF PERSONS EVACUATED
16. THREAT TO PRIVATE PROPERTY DWELLINGS: a. NUMBER b. VALUE $
17. NAME AND LOCATION OF COMMUNITY THREATENED
18. FARMS AND RANCHES: NUMBER VALUE 1. OUTBUILDINGS ___ ____ ___ ____ 2. ANIMALS ___ ____ ___ ____ 3. FARM EQUIPMENT UNITS & VEHICLES ___ ____ ___ ____ 4. CROP & GRAZING LAND (Acres) ___ ____ ___ ____		BUSINESS AND INDUSTRY NUMBER VALUE 1. BUSINESS CONCERNS ___ ____ ___ ____ 2. PRIVATE UTILITIES ___ ____ ___ ____
19. THREAT TO PUBLIC FACILITIES NUMBER VALUE a. BUILDINGS ___ ____ ___ ____ b. OTHER (Specify by type, ___ ____ ___ ____ number and value)		20. THREAT TO NATURAL RESOURCES a. NUMBER: 1. ACRES___ ____ 2. VOLUME___ ____ 3. VALUE $___ _________ b. WATERSHED: NUMBER VALUE 1. POTABLE WATER ___ ____ ___ ____ SUPPLY 2. FISHING STREAMS & ___ _____ ___________________ SPAWNING SITES 3. IRRIGATION ___ ________________________ 4. FLOOD CONTROL ___ ________________________
21. RECREATION (Type and extent of use)
22. WILDLIFE (Type threatened: birds, fur-bearing animals, big game, etc.)
23. ADDITIONAL REMARKS (Fire situation)

Page 3 of 4 pages

IV. STATE ASSESSMENT
24. STATE FORESTER'S ASSESSMENT OF SITUATION
25. TYPE AND AMOUNT OF FEDERAL OR OTHER ASSISTANCE NEEDED (Manpower, equipment, funds, etc.)
FEDERAL AGENCY CONTACT
26. NAME OF FEDERAL AGENCY, IF ANY, CONTACTED (Forest Service of Bureau of Land Management)						27. PHONE NO.
GOVERNOR/AUTHORIZED REPRESENTATIVE
28. NAME OF GOVERNOR'S AUTHORIZED REPRESENTATIVE				29. PHONE NO. a. Day		b. Night
30. LOCATION
31. STATE FLOOR COST		32. AVERAGE FY FIRE COST
NOTE: In making this request, the Government agrees to abide by provisions contained in FEMA-State Agreement for Fire Suppression Assistance under Section 420, PL 93-288 as amended. This request must be signed below by the Governor personally or by his authorized representative, whom he has previously authorized to sign this request in the FEMA-State Agreement.
33. SIGNATURE	34. TITLE				35. DATE
FOR FEMA USE ONLY
36. NAME OF PERSON WHO RECEIVED INITIAL OFFICIAL REQUEST			37. DATE		38. TIME
39. REMARKS

Page 4 of 4 pages