Form 009-0-3 Declaration and Release Form

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DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

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O.M.B. No. 1660-0002
Expires August 31, 2013

DECLARATION AND RELEASE

DECLARATON AND RELEASE

In order to be eligible to receive FEMA Disaster Assistance, a member of the household must be a citizen, non-citizen national or qualified alien of the
United States. Please read the form carefully, sign the sheet and return it to the Inspector, and show him/her a current form of photo
identification. Please feel free to consult with an attorney or other immigration expert if you have any questions.
I hereby declare, under penalty of perjury that (check one):
I am a citizen or non-citizen national of the United States.
I am a qualified alien of the United States.
Print full name and age of minor child:I am the parent or guardian of a minor child who resides with me and who is a citizen, non-citizen national
or qualified alien of the United States. Print full name and age of minor child:

By my signature I certify that:

* Only one application has been submitted for my household.

* All information I have provided regarding my application for FEMA disaster assistance is true and correct to the best of my knowledge.
* I will return any disaster aid money I received from FEMA or the State if I receive insurance or other money for the same loss, or if I do
not use FEMA disaster aid money for the purpose for which it was intended.
I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain disaster aid, it is a violation
of federal and State laws, which carry severe criminal and civil penalties, including a fine up to $250,000, imprisonment, or both
(18 U.S.C. §§ 287, 1001, and 3571).
I understand that the information provided regarding my application for FEMA disaster assistance may be subject to sharing within the
Department of Homeland Security (DHS) including, but not limited to, the Bureau of Immigration and Custom Enforcement.
I authorize FEMA to verify all information given by me about my property/place of residence, income, employment and dependents in
order to determine my eligibility for disaster assistance; and
I authorize all custodians of records of my insurance, employer, any public or private entity, bank financial or credit data service to release
information to FEMA and/or the State upon request.
NAME (print)

SIGNATURE

DATE OF BIRTH

INSPECTOR ID NO.

FEMA APPLICATION NO.

DISASTER NO.

ADDRESS OF DAMAGED PROPERTY

CITY

STATE

DATE SIGNED

ZIP CODE

PRIVACY ACT 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; 4 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 quality control purposes.
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 form is estimated to average 2 minutes per response. The burden estimate includes the time for reviewing instructions,
gathering data, and completing and submitting the form. This collection of information is required to obtain or retain benefits. You are not required to
complete this collection of information unless a valid O.M.B. control number is displayed in the upper right corner of this form. Send comments
regarding the accuracy of the burden and 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.
FEMA Form 009-0-3 AUG 10

REPLACES ALL PREVIOUS EDITIONS.