EOPSS-MEMA

MEMA Time Extension Request Form

To: Assistant Director for Mitigation and Recovery
Massachusetts Emergency Management Agency
400 Worcester Road
Framingham, MA 01702

Choose your MEMA Programs Coordinator(Required)

Select your MEMA POC

Date

Time

Name of person submitting request(Required)

First Last

Official Job Title(Required)

Applicant Name(Required)

Address(Required)

Street Address City State ZIP Code

Email(Required)

Phone(Required)

Choose Disaster #(Required)

Project #(Required)

Enter Project # for requested time extension.

Name of Damaged Facility(Required)

E.g. Brightview Elementary School

Address/ Location of Damaged Facility(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Current Status of Work(Required)

Provide a brief summary of current work status.

Reason(s) Why Work is Delayed(Required)

Time extension requests are evaluated based on extenuating circumstances or unusual project requirements beyond the control of the sub-recipient.

Projected Completion Date(Required)

Enter date work is project to be competed.

% of Work Complete(Required)

Provide a Project/ Construction Schedule(Required)

Enter an actual or anticipated project/ construction schedule to include activity and dates(s).

Do You Have Backup Documentation to Attach?(Required)

Upload Backup Documentation

Drop files here or

Accepted file types: jpg, doc, xls, pdf, Max. file size: 50 MB.

Note: