FEMA Form 90-69D Temporary Housing Program - Receipt for Government Prope

O.M.B. Number:
E x p i r a t i o n Date:

U.S. Department of Homeland Security
FEDERAL EMERGENCY MANAGEMENT AGENCY

Receipt for Government Property
(Temporary Housing Unit)

I

FEMA Application #
FEMA DR #

Date of Declaration

Address of Property
Description of Property
Manufactured Housing Unit
.Other (specify)
Authorized Users in Household
Name
Name
Name
Name
Name Name
Name
Name

Location (StateICounty)
Lot #

Furnished
- Unfurnished

# Bedrooms
# Baths

Age Age Age Age Age Age Age Age -

-

Sex Sex
Sex Sex Sex Sex Sex
Sex --

I understand that FEMA is allowing me to use the above unit under a revocable license
for the temporary housing of my household because: the President has declared a major
disaster or emergency in my state; I am not able to live in my pre-disaster primary
residence due to this event; and FEMA has determined my household to be eligible for
housing assistance under 42 U.S.C. 5174 and 44 CFR 206.1 10-118. I understand that, if
not revoked earlier, this license will automatically expire 18 months from the date of the
President's declaration of a mzjor disaster or emergency or at the end of any extension to
the 18-month period of assistance granted under 42 U.S.C. 5174(c)(l)(B)(ii).

I acknowledge receiving the above unit as temporary housing for my household's use
only. I understand that my household's continued use of this unit is subject to the
attached "Conditions for Use of Government Property", as well as FEMAYs
discretionary decision to continue the direct housing assistance program at this location.

I understand that any failure to comply with these "Conditions for Use" or any decision
by FEMA to terminate the direct housing program at this location may result in my
household being required to vacate this unit and return the unit's keys to FEMA as soon
as possible, but no later than the date set forth in a written Notice of Revocation (usually

FEMA Form 90-69D,
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within 15 days of the Notice). I understand that I am signing this form on behalf of all
members of my household listed above as authorized users.

-

Signature of Primary Authorized User

Date

Witness

Title

FEMA Form 90-69D.

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U.S. Department of Homeland Security
FEDERAL EMERGENCY MANAGEMENT AGENCY

TEMPORARY HOUSING PROGRAM (6 408)
Conditions for Use of Government Property
(Temporary Housing Unit)
OWNERSHIP/CONTROL.
The U.S. government owns or leases the temporary housing unit described in the
attached "Receipt for Government Property". The unit is federal property, and the
U.S. government retains the right to control its use at all times. This includes the
right to revoke my household's license to use the unit at any time with a written
notice and to enter the unit to make inspections or repairs with 24 hours notice (no
prior notice is required in an emergency as determined by FEMA). I understand that
FEMA is providing this unit as a discretionary benefit under 42 U.S.C. 5 174 and 44
CFR 206.1 10-1 18 and that at any time I may be given a written Notice of Revocation
requiring me to vacate the unit and return the unit's keys to the U.S. government as
soon as possible, but no later than the date set forth in the Notice of Revocation.
DUTY TO MEET CONTINUING ELIGIBILITY REQUIFZEMENTS.
FEMA requires all recipients of direct housing assistance under its temporary housing
program to continue to meet, certify, and/or document their compliance with, the
criteria for eligibility for such assistance in order to continue receiving the assistance.
I understand that the eligibility requirements for temporary housing assistance are set
forth in 44 CFR 206.1 10-1 18 and that, if FEMA determines I have not met these
requirements, I will be given a written Notice of Revocation requiring me to vacate
the unit and return the unit's keys to the U.S. government as soon as possible, but no
later than the date set forth in the Notice of Revocation.
DUTY TO OBTAINJACCEPT ALTERNATE HOUSING.
I understand that FEMA requires all recipients of direct housing assistance under its
temporary housing program to obtain and occupy permanent housing at the earliest
possible time. I agree to make a diligent effort to obtain permanent housing as soon
as possible and to establish a permanent housing plan for my household. I also agree
that, if FEMA determines adequate alternate housing is available, my household will
accept that alternate housing and leave this temporary housing unit as soon as
possible, but no later than the date set forth in a written Notice of Revocation.
DUTY TO COMPLY WITH ENFORCEMENT OR REMOVAL ACTION.
I agree to comply with any Notice of Revocation by vacating this temporary housing
unit and returning the unit's keys to the U.S. government as soon as possible, but no
later than the date set forth in the Notice of Revocation. I also agree to be responsible
for my household's personal property which is placed in the unit at my sole risk and
to remove it promptly from the unit upon Notice of Revocation. I understand that, if I
do not comply with any Notice of Revocation, FEMA may take steps to remove the

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members of my household and their personal property from the unit using any
enforcement authorities deemed appropriate by FEMA. I agree to hold harmless
the U.S. government and any of its agencies, agents, contractors, and
subcontractors, for damages of any type whatsoever either to property or
persons resulting from such enforcement actions. .
DUTY OF INSURED APPLICANTS TO REIMBURSE FEMA.
I understand that FEMA requires all recipients of direct housing assistance under its
temporary housing program to offset the value of the direct assistance provided by
FEMA against any insurance proceeds or recoveries they receive. If my household is
eligible for any payments or allowances from private insurance that can be used for
temporary housing needs, such as Additional Living Expenses (ALE), I agree to file a
claim for such insurance benefits and to pay FEMA for the cost of using this
temporary housing unit (as determined by FEMA) up to the limits of the insurance
recovery for monthly housing expenses.
DUTY TO PAY CHARGESDAMAGES.
Damages may include any charges deemed appropriate by FEMA for failing to vacate
the unit and return its keys to the U.S. government by the date set forth in a written
Notice of Revocation, as well as any charges, such as legal fees, associated with
enforcement actions to remove my household from the unit. I agree to pay FEMA for
any damages resulting from the violation of any of the rules set forth below or from
the failure to comply with any of these "Conditions for Use".
RULES FOR CONTINUED USE OF HOUSING UNIT.
I understand that any violation of the rules listed below may result in my household
being required to vacate the temporary housing unit and return the unit's keys to
FEMA immediately. I agree to follow these rules and to pay FEMA for any damages
resulting from the violation of any of these rules. I understand that I and all members
of my household must:
A. Pay all utility charges, including deposits, for the housing unit, if
applicable.
B. Keep the unit, any furnishings, and the surrounding area in a clean and
orderly condition, less ordinary wear and tear; and assure that items or
debris of any kind which may cause a possible fire hazard are not placed
near the unit's outside vents.
C. Notify FEMA when any damage or defect is found in the unit.
D. Not make any major repairs, additions, structural alterations, or changes to
the unit and any furnishings without FEMAYsprior written consent.
E. Not make any changes to the area surrounding the unit without FEMA's
prior written consent, except that FEMA's consent is not required for
altering the surrounding area on private property when the property owner
is the unit's occupant or when the private property owner's prior written
consent has been obtained.
F. Not move the unit to another location.

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G. Provide a right of entry signed by the landowner for any private property
site when requested by FEMA and allow FEMA onto the property for
inspections, repairs, or removal of the unit.
H. Not allow any lien or obligation to attach to this license or to the unit.
I. Not change the locks or install any security system without FEMA's prior
written consent, or otherwise impede access by FEMA.
J. Not allow any additional people (other than those listed as authorized
users above) to live in the unit and notifj..FEMA within 7 days in writing
of any change in this list of authorized users.
K. Not transfer or assign this license to any person except to another
authorized user listed above.
L. Use the unit continuously as housing and notify FEMA immediately in
writing if leaving the unit for any period of time greater than 30 days.
M. Respect the rights and privacy of other individuals in any group site or
commercial park, which includes not causing or permitting any disturbing
noises, any objectionable or improper conduct, or any dangerous activities.
N. Comply with all rules for a group site or commercial park AND comply
with all relevant local ordinances for any private property site.
0. Not engage in any illegal/criminal behavior or allow any illegal/criminal
behavior to occur in the housing unit or the surrounding area.

HOLD HARMLESS AGREEMENT
I hereby release, discharge, and waive any action, either legal or equitable, that might
arise out of any activities on the premises of the temporary housing unit or the
surrounding area. I agree to hold harmless the U.S. government and any of its
agencies, agents, contractors, and subcontractors, for damages of any type
whatsoever either to property or persons resulting from its furnishing of housing
assistance to my household.
ACKNOWLEDGEMENT.
I understand that I am not a tenant, but have merely been granted a revocable license to
use government property for temporary housing while my pre-disaster primary residence
is unavailable because it was damaged in a federally-declared major disaster or
emergency. I acknowledge that I am paying no rent or fees for the use of this
government property and that 1have no property interest in the unit I am being permitted
by the U.S. government to use as temporary housing. I understand that the rules and
procedures governing such federal disaster assistance are set forth in the Robert T.
Stafford Disaster Relief and Emergency Assistance Act, P.L. 93-288, codified at 42
U.S.C. 5121-5206, and at 44 CFR Part 206. I am signing this form on behalf ofall
members of my household.
Signature of Primary Authorized User
(Head of Household)

Date

Witness

Title

FEMA Form 90-69D,

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PRIVACY ACT STATEMENT
The Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5s
5 121-5206, authorizes the collection of this information. The primary use of this
information is to determine your eligibility to receive FEMA disaster assistance.
Disclosures of this information may be made: Upon written request, to federal and state
agencies providing disaster assistance, as well as to local governments or voluntary
agencies from which you are seeking assistance, so that assistance efforts or benefits are
not duplicated; to agencies, organizations, and institutions as necessary for FEMA to
obtain information from them in making eligibility determinations; to federal, state, and
local government agencies to promote hazard mitigation planning and enforcement; to
law enforcement agencies or professional organizations where there may be violation or
potential violation of law; to a federal, state, or local agency when we request information
relevant to an Agency decision concerning issuance of a grant or other benefit, or in
certain circumstances when a federal agency requests such information for a similar
purpose from us; to a Congressional office in response to an inquiry made at the request
of the individual; to the Office of Management and Budget (OMB) in relation to private
relief legislation under OMB Circular A-19; and to the National Archives and Records
Administration in connection with records management inspection conducted under the
authority of 44 U.S.C. $5 2904 and 2906. Furnishing this information is voluntary, but
failure to do so may delay or prevent provision of disaster assistance.

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes per response.
The burden estimate includes the time for reviewing the form, reading the legal rules in
the form, and completing and submitting the form. You are not required to respond to
this collection of information unless a valid OMB control number is displayed in the
upper right corner of 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, D.C. 20472, Paperwork Reduction Project
(1 660-0002). NOTE: Do not send your completed form to this address.

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FEMA Form 90-69D.