009-0-5 Temporary Housing Program - Receipt for Government Prope

OMB 1660-0002 Expires July 31, 2015
FEMA DR NUMBER

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

RECEIPT FOR GOVERNMENT PROPERTY (Revocable License)
INDIVIDUAL AND HOUSEHOLD PROGRAM
FEMA APPLICATION NUMBER

DATE OF DECLARATION

LOCATION (STATE/COUNTY)

LOT NUMBER

ADDRESS OF PROPERTY

Bar Code Number

VIN

DESCRIPTION OF PROPERTY
Manufactured Housing Unit
Trailer Trailer

Park Model

Furnished

Number of bedrooms

Other

Number of bathrooms

(Specify)

AUTHORIZED USERS IN HOUSEHOLD

NAME

AGE

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 206.110-118. I understand that, if not
revoked earlier, this license will automatically expire 18 months from the date of the President's declaration of a major disaster or emergency.
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 FEMA's 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 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.

Head of Household
Signature of Authorized User

Date

Title

Witness

FEMA Form 009-0-5, AUG 12

REPLACES ALL PREVIOUS FEMA Form 90-69D

Part -1 Page 1

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
RECEIPT FOR GOVERNMENT PROPERTY (Revocable License)
INDIVIDUAL AND HOUSEHOLD PROGRAM
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. 5174 and 44 CFR 206.110-118 and that at
any time I may be given a written Notice of Revocation requiring me to vacate the unit and return the units 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 REQUIREMENTS
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 206.110-118 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 units 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 OBTAIN/ACCEPT 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 acknowledge that I and the listed occupants will comply with any written notice requiring me to vacate the unit by moving out of the temporary housing
unit, removing all personal property, and returning the unit's keys to the U.S. Government no later that the date set forth in the notice. 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 a written notice
requiring me to vacate the unit. I acknowledge that, if I do not comply with a written notice requiring me to vacate the unit, the U.S. Government may take
steps to remove the members of my household and their personal property from the unit using any enforcement authorities deemed appropriate. I
understand that FEMA reserves the right to assess charges and fees if I fail to comply with enforcement or removal action (44CFR 206.117(b)(1)(ii)(H)). 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 CHARGES/DAMAGES
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 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".

FEMA Form 009-0-5, AUG 12

REPLACES ALL PREVIOUS FEMA Form 90-69D

Part -1 Page 2

RULES FOR 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.
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
FEMA's prior 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.
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 notify
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.
O. Not engage in any illegal/criminal behavior or allow any illegal/criminal behavior to occur in the housing unit or the
surrounding area.
FOR CONTINUED USE OF HOUSING UNIT DURING EXTENSIONS
(44 CFR 206.117(b)(1)(ii)(F))
I understand that if FEMA authorizes an extension of the Temporary Housing Program, the conditions set forth in this license will remain in full
effect. I understand that if I remain in the unit during an extension, FEMA reserves the right to charge me rent for the unit at the Fair Market
Rate.

Head of Household
Signature of Authorized User

FEMA Form 009-0-5, AUG 12

REPLACES ALL PREVIOUS FEMA Form 90-69D

Part -2 Page 1

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 predisaster primary residence is unavailable because it was damaged in a federally-declared major disaster or emergency. 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. 5121-5207, and at 44 CFR Part 206. I am signing this form on behalf of all members of my household.

Head of Household
Signature of Authorized User

Date

Witness

Title
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 administrating financial assistance
under a Presidentially-declared disaster. Additionally, information may be reviewed within FEMA for quality assurance purposes and used to assess
FEMA's customer service to disaster assistance applicants.
ROUTINE USE(S): The information on this form may be shared outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of
1974, as amended. This includes sharing this information with state, tribal, local and voluntary organizations to enable you to receive additional disaster
assistance and as necessary and authorized by 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.

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 10 minutes 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 (1660-0002) NOTE: Do not send your completed form to this address.

FEMA Form 009-0-5, AUG 12

REPLACES ALL PREVIOUS FEMA Form 90-69D

Part -2 Page 2