Request for Information Letter

U.S. Department of Homeland Security
FEMA
National Processing Service Center
PO Box 10055
Hyattsville, MD 20782-8055

Date: 02/09/2017

FEMA Application No.

Disaster No.

Dear :
FEMA requests the following information to process a review of your debt. The requested information will be
reviewed to determine whether you qualify for a payment plan or a compromise, partial or full, to resolve your debt.
A compromise is an agreement to accept less than the full amount of the debt owed in satisfaction of the debt.
Please answer all the questions on the enclosed forms, provide requested signatures, include all the documents
requested below and mail all materials to the address printed on this letter within 30 days from the date of this letter.
You may also fax all requested documents to 1-800-827-8112. If the information is not furnished, your eligibility
for a payment plan or compromise may be affected.


DEBT COLLECTION FINANCIAL STATEMENT (COMPLETE and SIGN THE ENCLOSED
FORM)



MOST RECENTLY FILED and SIGNED TAX RETURN OR IF YOU ARE NOT REQUIRED TO
FILE A TAX RETURN, SIGN and RETURN THE STATEMENT BELOW.
I, ________________________, certify that I am not required to file a tax return.
____________________________
Signature



__________
Date

SUMMARY OF MONTHLY EXPENSES -- (COMPLETE THE ENCLOSED "HOUSEHOLD
EXPENSE
LISTING" FORM)
Note: These are regular costs that are NOT included on the enclosed Debt Collection Financial Statement.
Rather, these are personal expenses that occur monthly or at least regularly, such as: food, clothing, utilities,
phone, auto insurance, fuel, maintenance, home insurance, medical bills, prescriptions, health insurance
premium, and other regular costs. ESTIMATE THE AVERAGE COSTS PER MONTH, EVEN IF THE
COSTS CHANGE EACH MONTH.

If you believe you have special circumstances affecting your ability to pay your debt, please provide a letter
explaining your situation and include any supporting documentation. Special circumstances that may receive
consideration include advanced age, serious illness or any other factors that have an impact upon your ability to pay
the total amount due and continue to provide for the necessary living expenses for you and your family.
After returning the requested information to FEMA, please allow us time to process your request. You will receive a
letter of determination from FEMA explaining the results of our review of your debt upon completion.

Please understand that FEMA remains committed to working with you throughout this process. We want to be sure
you have all the information necessary as you prepare the materials you will be sending back to us.
If you have questions or need help, please call 1-800-816-1122 between 9:00 AM and 6:00 PM, Eastern Time,
Monday through Friday.
Sincerely,

Debt Collection Officer

FRFI