U.S. DEPARTMENT OF HOMELAND SECURITY | TECHNICAL ASSISTANCE: PREPAREDNESS & PROGRAM MANAGEMENT 
TECHNICAL ASSISTANCE (TA) REQUEST FORM 

TA Requestor: 
(text) 


Date: 
(text) 


(State or local jurisdiction requesting TA) 

Please describe the nature and extent of the issue or problem you are experiencing: 
(text) 


Catalog Title of TA Service Requested: 
Level of Assistance: 
Jurisdiction Level to Receive TA: 



(checkbox) Unchecked
State 


(checkbox) Unchecked
Local 


(checkbox) Unchecked
Both 


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Regional 

Additional Information: 
(text) 


Request is consistent with the technical assistance goals, projected needs, and priorities 
addressed in the statewide strategy. 

. 
Yes. If “yes,” please list the strategy goal/objective: 
(checkbox) Unchecked
. No. If “no,” please attach an explanation or strategy update justifying this need for technical 
assistance or redefining goals, objectives, and priorities. 
(checkbox) Unchecked
(text) 
(text) 
Desired Delivery Dates/Timeline: 
Anticipated Number of TA Participants: 
Additional Information on Specific Needs: 
(text) 



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TA Requestor Point of Contact Information: 
Name: 
(text) 
Title: 
(text) 
Phone Numbers: 
(text) 
E-mail Address: 
(text) 
________________________________ 
(text) 
________________________________ 
(text) 
SAA Authorized Signature FEMA Program Analyst Signature 
________________________________ 
(text) 
________________________________
(text) 
Date Date 


(text)