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

OMB No. 1660-0061 Expires October 31, 2014

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
INDIVIDUALS AND HOUSEHOLDS PROGRAM
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 circle indicating how you are
billed for the housing expense.
7. Housing Costs (See Instructions for Definitions of Expenses)
Expense

Pre Disaster
or
Prior Reported

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.

QUESTIONS OR NEED ASSISTANCE?
If you have any questions about completing this document, you should call the FEMA Disaster Helpline at 1-800-621-FEMA
(3362) (hearing/speech impaired only: 1-800-462-7585) as soon as possible.
FEMA Form 010-0-12, (10/11)

Instructions for Completing Your Application for Continued Temporary Housing Assistance
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 circle 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 circle for "Other." FEMA will recalculate the income to a Monthly
cycle. See example below:
9. Income Information for Persons 18 years of Age and Older Residing in Current Temporary Residence
Gross Income
Name

Pre Disaster
or
Prior Reported

Current

Manie Quin

$3578.00

$3578.00

Shade
if Document is
Weekly
Attached

Pay Cycle
Bi-Monthly

Monthly

Quarterly

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

FEMA Form 010-0-12, (10/11)

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 Helpline at 1-800-621-FEMA
(3362) (hearing/speech impaired only: 1-800-462-7585) as soon as possible.

FEMA Form 010-0-12, (10/11)

OMB No. 1660-0061 Expires October 31, 2014

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
INDIVIDUALS AND HOUSEHOLDS PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
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): FEMA collects this information for to determine eligibility and to administer financial assistance under a Presidentially-declared disaster. FEMA may also review
this information internally for quality assurance control purposes and use it to assess FEMA's customer service to disaster assistance applicants.
ROUTINE USE(S): FEMA may share the information collected on this form externally as permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes sharing
this information with state, local, tribal and voluntary organizations to enable individuals to receive additional disaster assistance and as necessary and authorized by other routine uses published
in DHS/FEMA-008 Disaster Recovery Assistance Files System of Records, 78 Fed. Reg. 25,282 (April 30, 2013), 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.

2. DISASTER NO.

1. APPLICANT NAME
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:

FEMA Form 010-0-12, (10/11)

Pre Disaster
or
Prior Reported

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 and Older Residing in Current Temporary Residence
Gross Income
Name

Pre Disaster or
Prior Reported

Current

Shade if Document
is Attached

Pay Cycle
Weekly

Bi-Monthly

Monthly

Quarterly

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

FEMA Form 010-0-12, (10/11)

Date

Date Form Mailed to Applicant