Form 009-0-1 Application / Registration for Disaster Assistance

REC. #

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0002
Exp. August 31, 2013
(see reverse side)

APPLICATION/REGISTRATION FOR DISASTER ASSISTANCE
2. Language

1. Name of Applicant (last, first, MI)
6. Damaged Phone #

3. Date of Birth

DR #
APP. DATE

4. Applicant Social Security No.

7. Current Phone #

Alt. Damaged Phone#

Loss Date

5. Email

Alternate Cell Phone No.

Note:
8. Damaged Property Address

No.

Street

Apt/Lot

City.

State

9. Mailing Address

No.

Street

Apt/Lot

City.

State

Zip

County
Zip

Same as Damaged Address
10. Cause of Damage
Earthquake

Flood

Sewer/Backup

Seepage

Fire/Smoke/Soot/Ash

Ice/Snow

Hail/Rain/Wind Driven Rain

No

Unknown

12. Personal Property Damage

Yes

11. Home Damage
14. Current Location

Primary Home

15. Residence Type:

Travel Trailer

16, Primary Residence

Yes

Hotel/Motel
Mobile Home.

Home-Single/Duplex

No

17. Do You

No

Yes

Yes

13. Utilities Out

Mass Shelter

Other

Apt.

Condo/Townhouse

Other

Own

Rent

Family/Friends

Other

Power Surge/Lightning

Tornado Wind

Yes

18. Is your home accessible?
No, due to mandatory evacuation

19. Home/Personal Property Insurance

No

No, due to disaster

20. Disaster Related Expenses (for uninsured or underinsured expenses)

Insurance Type

Insurance Company Name

Expense Type

YES

NO

IF YES and have insurance, Insurance Company Name

Medical
Dental
Funeral
I have no insurance for my home or personal property
21. All Vehicles Damaged due to Disaster
Vehicle Information
Year

Make

Damaged?

Model

YES

NO

Drivable?
YES

Comprehensive Insurance?
YES

NO

NO

22. Other Expenses:

Insurance Company Name

Liability Insurance?
YES

Registered?
YES

NO

NO

23. Emergency Needs

Chainsaw

Wet/Dry Vac

Generator

Dehumidifier

Food

Shelter

Clothing

24. Special Needs: Did you, your spouse, or any dependents have help or support doing things like walking, seeing, hearing, or taking care of yourself before the disaster and have you lost that help or
support because of the disaster?
YES
NO
If Yes, Select all that apply. Mobility, such as:

Wheelchair

Walker

Cane

Cognitive/ Developmental Disabilities/Mental Health, such as: Personal care attendant,
etc.
Hearing or speech, such as: Hearing aid, sign language interpreter, TDD/TTY,
text messaging and/or other accessible communication device

(Select all that apply)

Lift

Bath Chair

Personal Care Attendant, etc.

Other

Vision, such as: Glasses, white cane, service animal, Braille, or other accessible communication device, magnifier
25. Occupants living in primary residence at time of disaster
Last Name

MI

First Name

Relationship

Social Security Number
(Applicant First, Please)

Age

Dependent?
YES
NO

26. BUSINESS DAMAGES
Self Employment is primary income?

YES

Own/Represent a business or rental property affected by disaster?

NO

27. Number of claimed dependents

29. Electronic Funds Transfer

28. Combined family pre-disaster gross income

Income Refused

$
Bi-Weekly

Semi-Monthly

Quarterly

Yearly

Checking

Account No.:

30. Social Security Administration's Change of Address Request
When do you want this change to take effect?

Make the change effective:

31. Comments

31. FEMA Representative

FEMA Form 009-0-1

YES

NO

NO

Institution Name:
Account Type:

Weekly

YES

REPLACES ALL PREVIOUS EDITIONS 90-69

Savings

Routing No.

(9 digits)

Application/Registration for Disaster Assistance Instructions
1. Enter the last name, first name, and middle initial of the application. Jr., Sr., etc. follow the last name.
2. Enter the language that the applicant speaks. If the applicant speaks English, leave blank.
3. Enter the date of birth of the applicant.
4. Enter the applicant's social security number (SSN). If the applicant does not provide a SSN, processing of the applicant may be delayed.
5. Enter e-mail address (if available).
6. Do NOT include a beeper/pager number in any of the phone number fields. Damaged Phone number: enter the phone number used in the applicant's home at the time of the
disaster even if the number is currently working.
7. Current Phone No. Enter the current phone number where the applicant can be reached. Alternate/Cell Phone No.: enter a work phone number or the phone number of a friend,
relative, or neighbor that FEMA can use to leave a message for the applicant. Note: include extension number (if available).
8. Enter the full physical street address at which the damage occurred. Do not enter a P.O. or general delivery address.
9. Enter the applicant's mailing address. It may or may not be the same as the Damaged Property Address or where the applicant is now living. The Mailing Address may be a post
office or general delivery address. If it is the same as the damaged property address, check the box for the same.
10. Check Cause of Damage (more than one cause may be checked). Other causes of damage may include explosion, drought, and riot. If more than the home was damaged (e.g., auto
was flooded), please describe in the Comments section in item no. 30.
11. If the applicant has damage to the home (e.g., electrical, heating, floors, walls, ceilings, and foundation), check Yes. If home damage is unknown, check Unknown.
12. If the applicant had Personal Property Damage, e.g., appliances, clothing, and/or furniture), check Yes.
13. If the applicant's utilities are not working (out), check "Yes." Utilities may include sewer, water, gas, electricity, and/or heating.
14. Check the current Location where the applicant is living.
15. Check the type of residence that was damaged (e.g., Travel Trailer, Mobile Home, House-Single/Duplex, etc.). Other may include, for example, homeless or RV.)
16. If the person lived in the home more than six months of the year, or the applicant lists it as the address of his/her Federal Tax Return, or the applicant files a homestead exemption,
or the applicant uses it as a voter registration address, check "Yes."
17. If the applicant is named on the deed, or the applicant maintains the home and pays the taxes but pays no rent, or the applicant has lifetime occupancy rights while not holding
legal title to the home, check Own. Check "Rent" if the applicant does not meet any of the above ownership criteria, even if the applicant pays no rent.
18. If the home is Accessible after the disaster, check "Yes." Inaccessible may include disruption or destruction of transportation routes or other obstructions that prevent the applicant
from gaining entry to the damaged home. If the applicant is unable to enter the home, determine if it's Due to the Disaster, or Due to Mandatory Evacuation and check appropriately.
19. List the type of insurance that the applicant held at the time of the disaster for the home and/or personal property, including but not limited to sewer backup, earthquake. Include
the name of the insurance company. If no insurance, check I have no insurance for my home or personal property.
20. If the applicant incurred a Medical, Dental, Funeral, and/or Moving Storage Expense related to the disaster, check "Yes." Under Insurance company, provide the name of applicant's
insurance company if they had insurance for that expense.
21. Enter vehicles for the household if all were damaged due to the disaster and “No” Comprehensive Insurance. Enter their year, make, and model. Do not enter any vehicle information if one
vehicle is drivable. Do not enter any vehicle information if “Yes” to Comprehensive Insurance. Enter “Yes” if vehicle is registered. Enter the name of the insurance company if applicant has
insurance. If more space is needed, use the space in Item #29.
22. If the applicant had Other Expenses, check the types of expenses that apply (i.e., generator, chainsaw).
23. If the applicant has Emergency Needs (e.g, food, clothing, shelter), check the appropriate box for type of need.
24. Question relates to special needs. The Americans with Disabilities Act (ADA) defines a disability as "a physical or mental impairment that substantially limits one or more of the
major life activities of such individual." 42 USC 12102(2) (A). If the registrant or household member has such a disability and was affected by the disaster, please mark all of the
areas of disability that apply.
25. List information for the applicant and all other persons/dependents who consider the home to be their primary residence at the time of the disaster, whether or not they are related
to the applicant. It is important that the applicant's and co-applicant's SSN is included. Answer if they are a dependent or not.
26. LOST WORK? If the applicant or a member of the applicant's household lost work or became unemployed as a result of the disaster for which they will not be compensated,
check "Yes." An example is, if the family breadwinner was incapacitated or killed due to the disaster.
SELF EMPLOYMENT IS PRIMARY INCOME? Check appropriately.
OWNS/REPRESENTS BUSINESS OR RENTAL PROPERTY? Check appropriately.
27. Enter the number of claimed dependents as listed on the applicant's Federal Tax Return.
28. Enter the combined family pre-disaster gross Income. (This is the amount of income before any deductions, and may include money from employment, Social Security, retirement,
welfare, child support, stocks, interest, annuities, and savings or assistance from family and friends. It does not include food stamps or HUD Section 8 assistance.) Check the
appropriate frequency of pay (weekly, bi-weekly, monthly, semi-monthly, quarterly, or yearly). If income refused, check appropriate box.
29. If the applicant would like FEMA to automatically transfer assistance into their checking or savings account, check "Yes" next to Electronic Funds Transfer. Enter the name of the
applicant's financial institution. Enter the applicant's 9-digit routing no. (The routing no. is the 9-digit number that appears in the lower left hand corner of the check.) Indicate the
applicant's account type by marking the Checking or Savings box. Enter the applicant's account no. (The account number can be found at the center bottom of a check
immediately after the routing number, or can be found on a savings or checking account statement.) NOTE: Applicant name must be on the account.
30. Enter any additional comments as necessary.
31. Enter name of the FEMA representative filling out form.

PRIVACY STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act. as amended, 42 U.S.C. § 5121-5207 and Reorganization Plan No. 3 of 1978; 4 U.S.C.§§ 2904 and 2906; C.F.R. §
206.2 (a) (27); the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193) and Executive Order 13411. DHS asks for your SSN pursuant to the Debt Collection
Improvement Act of 1996, 31 U.S.C. § 3325 (d) and §7701(c) (1).
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administering financial assistance under a Presidentially-declared disaster.
Additionally, information may be reviewed internally within FEMA for a quality control purpose.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as
necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster Recovery Assistance Files System of Records (September 24, 2009, 74 FR 48763) and upon written request,
by agreement, or as required by law
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent the individual from receiving disaster
assistance. .

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average.3 hours 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 OMB 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, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0002) NOTE: Do not send your completed form to this address.

The Tele-Registration recording informs the respondent at the beginning of the registration intake of the Privacy Act and Paperwork Reduction Act (PRA) burden
disclosure information.

It is not necessary to complete grayed fields.