FEMA Form 010-0-12 Application for Continued Temporary Housing Assistance (

Instructions for Completing Your Application for Continued Temporary Housing Assistance
Please read these instructions prior to filling out your "Application for Continued Temporary Housing Assistance".
STEP ONE
Fill out the form. NOTE: After your initial "Application for Continued Temporary Housing
Assistance" is approved, the "Pre-Disaster or Prior Reported" column on the form will be auto-generated for you, using the
information provided by you in your previously approved request.
Items 1 - 6
Items 1 through 6 will be auto-generated for you, using the information provided by you at registration. If the information supplied on
the form is correct, you may move on to Item 7: "Housing Costs." However, if the information is incorrect, please check the box that is
incorrect and provide the updated information.
Current Mailing Address is the address you want FEMA to send you disaster assistance information, such as letters regarding your
eligibility for continued temporary housing assistance.
Current Phone is the phone number that FEMA can use to contact you about your application for continued temporary housing
assistance and other disaster assistance.
Item 7
You will need to supply the monetary amount of both pre-disaster and current expenses that are applicable to your household.
Next to the appropriate "Expense" enter the dollar amount of your bill or payment.
You must submit a copy of the document to prove the dollar amount included as a "Housing Cost." Shade in the circle next
to the "Expense" indicating that you have attached the document to your application. You must submit documentation that
can be validated; otherwise the amount will not be accepted.
To ensure proper calculation and evaluation of your Housing Costs, please shade in the oval indicating how you are billed
for the housing expense. See example below:
7. Housing Costs (See Instructions for Definitions of Expenses)
Expense

Pre Disaster
or
Prior Report

Current

Mortgage

$1495.00

$1495.00

Shade
if document is
attached

Payment Cycle (How You Are Billed)
Monthly Quarterly Bi-Annual
(1)
(3)
(6)

Annual
(12)

Other

Definitions for certain expenses have been provided below.
Home Insurance means typical homeowners, renters, flood, or earthquake insurance policy or any other type of insurance policy or
rider for the dwelling.
Housing Cost: means the rent and/or mortgage payments (including principal, interest, and real estate taxes), real property
insurance, and utility costs (not to include cable television, internet, and telephone service).
Housing Unit: means a house, apartment, hotel, motel, a manufactured home, recreational vehicle, or other readily
fabricated dwelling. A room or group of rooms in an occupied dwelling may qualify as a housing unit if the room(s) in which
the applicant and household live are separate from any other persons in the dwelling/building, and are generally available
to be rented by the public.
Item 8
If you are in a Housing Unit, in addition to providing a copy of your lease, you will have to provide the name and phone
number of the landlord.

Item 9
You will need to supply the pre-disaster and current income information for each individual 18 years of age or older who is residing at
your current temporary residence.
You must submit documentation to validate any amount you supplied on the form and you will also need to provide the
frequency at which the individual is paid by his or her employer. In the pay cycle box, please shade in the circle that is
applicable.
To ensure proper calculation and evaluation of your Household's Income, please shade in the oval indicating how often you
are paid. If you have more than one job, please list yourself separately for each job.
If your Pay Cycle is not listed, please shade in the oval for "Other." FEMA will recalculate the income to a Monthly cycle.
See example below:
9. Income Informations for Persons 18 years of Age Older Residing in Current Temporary Residence
Gross Income
Name

Pre Disaster
or
Prior Report

Current

Manie Quin

$3578.00

$3578.00

Shade
if document is
attached

Payment Cycle (How You Are Billed)
Monthly Quarterly Bi-Annual
(1)
(3)
(6)

Annual
(12)

Other

Income means: 1) Wages and salaries, overtime pay, commissions, fees, tips and bonuses and other compensation for personal
services; 2) Interest, dividends and other net income of any kind from real or personal property; 3) Full amount of periodic amounts
received from Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits and other similar
types of periodic receipts, including lump-sum amount or prospective monthly amounts for the delayed start of a periodic amount; 4)
Payments in lieu of earnings, such as unemployment and disability compensation, worker's compensation and severance pay; and 5)
Welfare assistance.
Item 10
You will need to check whichever box is applicable to your pre-disaster housing situation and your post-disaster housing plan. If you
plan on moving in with your friends/family, you must supply your projected move in date.
Item 11
Please read this section thoroughly. NOTE: All of the bullet points may not be applicable to your household situation. However, in order
to be eligible for Continued Temporary Housing Assistance, the information contained in those bullet points that are applicable to your
household situation must be true and accurate. If the information is not true to your situation, then you are not eligible for Continued
Temporary Housing Assistance and will not need to fill out this form.
Item 12
Once you have reviewed the form for accuracy, you will need to read the declarations statement and sign and date the form. When
signing the form, please use blue or black ink.
STEP TWO

Attach supporting documentation to application.

STEP THREE Submit the application and your supporting documents to FEMA.

QUESTIONS OR NEED ASSISTANCE?
If you have any questions about completing this document, you should call the FEMA Disaster Help line at 1-800-621-FEMA
(3362)
(hearing/speech impaired only: 1-800-462-7585) as soon as possible.

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
INDIVIDUALS AND HOUSING PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE

OMB 1660-0061
MM/YYYY

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1 hour 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. This collection of
information is required to obtain or retain benefits. 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 (1660-0061) NOTE: Do not send your completed form to this address

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: Furnishing this information is voluntary; however, failure to furnish the requested may delay or prevent the individual from receiving
disaster assistance.
1. APPLICANT NAME

2. DISASTER NO.

3. CURRENT MAILING ADDRESS

4. REGISTRATION NO

5. CURRENT PHONE

6. ALTERNATE PHONE

CHECK HERE IF CURRENT MAILING ADDRESS IS DIFFERENT AND PROVIDE NEW
ADDRESS BELOW:

CHECK HERE IF CURRENT PHONE IS DIFFERENT AND
PROVIDE NEW NUMBER BELOW:

IMPORTANT NOTICE: Requirements for Applying for Continued Assistance. In order for FEMA to effectively evaluate a continuing need for temporary
housing, it is necessary that we have you submit documentation on your pre-disaster and current housing costs, pre-disaster and current income and
verifiable documentation of income, recovery strategy, current lease/cancelled checks, and mortgage payment information.
7. Housing Costs (See Instructions for Definitions of Expenses)

Expense

Mortgage
Real Estate Taxes
(If paid separately from Mortgage)
Home Insurance
(If paid separately from Mortgage)

Rent for Housing Unit
Water
Electric
Gas
Oil
Propane
Sewer
Trash
Other 1:

FEM Form 010-0-12

Pre Disaster
or
Prior Report

Current

Shade if document
is attached

Payment Cycle (How You Are Billed)
Monthly
(1)

Quarterly
(3)

Bi-Annual
(6)

Annual
(12)

Other

8. Current Landlord Contact Information:

NAME

PHONE NUMBER

9. Income Information for Persons 18 years of Age Older Residing in Current Temporary Residence
Gross Income
Name

Pre Disaster or
Prior Report

Shade box
document
is attached

Current

Payment Cycle (How You Are Billed)
Monthly
(1)

Quarterly
(3)

Bi-Annual
(6)

Annual
(12)

Other

10. Permanent Housing Plan - (Recovery Strategy)
I am a RENTER and my permanent housing plan is to:
Locate a rental resource within my family's financial ability
Move in with friends/family

Projected Move In Date

I am a HOMEOWNER and my permanent housing plan is to:
Repair or rebuild my damaged home
Purchase a home using my disaster related assistance, including any insurance
Become a renter and locate a rental resource within my family's financial ability
Move in with friends/family

Projected Move In Date

11. Conditions for Receiving Continued Temporary Housing Assistance
My household understands that in order to be eligible for continued Temporary Housing Assistance, the following information must be true
and accurate:
• My household has a continuous need for Temporary Housing Assistance because our housing needs are not being met by another
source, i.e., my household is not receiving housing assistance from another public agency such as the U.S. Department of Housing and
Urban Development, U.S. Department of Veterans Affairs, a local housing agency, or any other agency or organization providing housing.
• My household does not own a secondary home or a vacation home within a reasonable commuting distance of our pre-disaster home.
• My household cannot live in and/or access our pre-disaster primary home due to the disaster.
• My household has looked and is continuing to look for but has not yet found an alternative, adequate home that is within reasonable
commuting distance of work and/or school and is within our financial means.
.• My household has been and is currently working to repair our pre-disaster primary home (Applicable only for those who have chosen to
rebuild their pre-disaster primary home).
If any of the above statements are not true to your situation, then you are not eligible for Continued Temporary Housing
Assistance and do not need to submit this form.

12. CERTIFICATION I understand that if I intentionally make false statements, submit fraudulent information, or conceal any
information in an attempt to obtain additional disaster assistance, it is a violation of federal and state laws, which carries
criminal and civil penalties, including fines, imprisonment, or both.
I hereby declare under penalty of perjury that the foregoing is true and correct.

Head of Household (Applicant/Co-Applicant) Signature

Date