Region IV Emergency Response Civil Money Penalty funds application CMP funds 2026

1. Click ‘Get Form’ to open the Region IV Emergency Response CMP application in the editor.
2. Begin by filling out the Nursing Home Background Information section. Enter the date of application, facility name, address, and contact details accurately.
3. In the Nursing Home Survey History section, provide dates of last surveys and any outstanding civil money penalty amounts. This information is crucial for your application.
4. Describe the emergent event in detail under the Emergent Event section. Include dates, number of residents affected, and type of emergency.
5. Select the funding category that corresponds to your request amount. Ensure you understand prohibited uses of CMP funds as outlined in the form.
6. Complete the Attestation Statement at the end of the application. Ensure all required signatures are obtained from relevant parties before submission.
7. Assemble all documentation into a single PDF file using Times New Roman font, size 12 for appendices, and submit electronically to your State Survey Agency.

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