Form FF-USFA-FY-21-112 FF-USFA-FY-21-112 Federal Hotel and Motel Fire Safety Declaration Form (Re

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Application Form to Add a New Listing

FF-USFA-FY-21-112 0MB No. 1660-0068 Expiration date: March 31, 2025

Use this form to report your property's compliance with the Hotel and Motel Fire Safety Act of 1990 (P.L. 101-391). There is no charge for this listing. This form is being submitted to add a previously unlisted property

to the National Master List.

Status: Initial application

Privacy notice Paperwork burden disclosure notice

Property information

Property type

General manager

Property name

Employer Identification Number

What's this?

Street address

P.O. Box

Optional

City/State: (not required) ZIP code

Property office phone number

Reservations phone number

Property fax

Optional

Property email

Website

Optional: Please start with https:// or http://

Smoke alarms/automatic sprinkler systems

Smoke alarm equipped

Each guest room is equipped with at least one hard-wired single station smoke alarm installed in accordance with National Fire Protection Association (NFPA) Standard 72. Note: smoke alarms that are solely battery operated do not qualify.

Yes No

Automatic sprinkler equipped

Number of floors

Sprinklers are required unless the property is three stories or fewer in height.

If sprinklers installed on or after Oct. 25, 1992

This property has an automatic sprinkler system installed in accordance with NPFA Standard 13 or 13R, whichever is appropriate, in accordance with the requirements of the Act.

If sprinklers installed before Oct. 25, 1992

This property has an automatic sprinkler system installed in compliance with an applicable standard (adopted by the governmental authority having jurisdiction, and in effect, at the time of installation), provided such standard required the placement of a sprinkler head in the sleeping area of each guest room.

This property is three or fewer stories in height

and is therefore exempt from the Act's automatic fire sprinkler requirements.

Declaration

By submitting this form, you attest that the information supplied on this form is true and accurate to the best of your knowledge and belief. Therefore, this property is entitled to be included in the National Master List of public accommodations compiled by the U.S. Fire Administration. This information is subject to verification by federal, state, and local fire authorities, and you are subject to fines of up to $10,000 and/or imprisonment for up to five years if you knowingly make false or fraudulent statements to the government.

Name

Title

Organization

Your phone number

Extension

Optional

Fax number

Optional

For verification purposes, please provide your email address. The address entered must belong to the person listed in the Name field above. If this is a new property listing, a confirmation email message will be sent to this address upon receipt of the application. If a reply email is not received within seven days, the application will be deleted.

Your email address

Submit

Paperwork burden disclosure notice

FF-USFA-FY-21-112 0MB No. 1660-0068 Expiration date: March 31, 2025

Public reporting burden for this data collection is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid 0MB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate ·and any suggestions for reducing the burden to: Information Collections Management,

Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0068) NOTE: Do not send your completed form to this address.