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

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB No. 1660-0061
INDIVIDUALS AND HOUSEHOLDS PROGRAM
Expires July 31, 2017
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 filled-in for you, using the information
provided by you in your previously approved request.
Items 1 - 6
Items 1 through 6 will be filled-in 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 dollar 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 each document to prove the dollar amount included as a "Housing Cost." This would include
documents such as your mortgage statement, rent receipts and utility bills. 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 verified; otherwise the amount will
not be accepted.
Under "Payment Cycle", 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)
(4)
(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, 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
In addition to providing a copy of your written and signed lease, you will have to provide the name and phone number of the
landlord. The lease must be signed by the applicant or co-applicant and the landlord.
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

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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
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 currently
living with you at your temporary residence.
You must submit documentation to verify each dollar amount you supplied on the form, and you will also need to provide how
often each individual is paid by his or her employer. Shade in the circle indicating you have attached a document to your application.
Shade in the circle indicating how often each individual is paid by his or her employer. If an individual has more than one job, please
list them separately for each job. If the pay cycle is not listed, please shade in the circle for "Other".
See example below:

9. Income Information for All Individuals 18 years of Age and Older Living in Current Temporary Residence
Gross Income
Name

Pre Disaster
or
Prior Reported

Current

Maria Quin

$1,495.00

$1495.00

Shade
if Document is
Weekly
Attached

Pay Cycle
Twice
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 permanent 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
receipts, etc.)

Attach supporting documentation to application (e.g. pay stubs, mortgage statements, lease, utility bills, rent

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

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
INDIVIDUALS AND HOUSEHOLDS PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE

OMB Control No. 1660-0061
Expires July 31, 2017

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, 500 C Street, SW, Washington, DC
20472-3100, Paperwork Reduction Project (1660-0061). NOTE: Do not send your completed form to this address.
PRIVACY NOTICE

AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 93-288, as amended, 42 U.S.C. §§ 5121 -5207; The Homeland Security Act
of 2002, P.L. No. 107-296, as amended, 6 U.S.C. §§ 311-321j; 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 Exec. Order No. 13411. Disaster Mitigation Act of 2000 (DMA 2000), P.L. 106-390,
amended the Stafford Act. Post-Katrina Emergency Management Reform Act of 2006, Pub. L. No. 109-295. Sandy Recovery Improvement Act of 2013 (SRIA), Pub. L. No.
113-2.
PRINCIPAL PURPOSE(S): FEMA collects and maintains your information in order to determine eligibility for and administer financial assistance under a Presidentiallydeclared disaster. Additionally, FEMA may review your information for quality assurance purposes to assess FEMA's disaster assistance customer service.
ROUTINE USE(S): FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their disaster assistance files outside of FEMA as
generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. FEMA may share the personal information of non-citizens, as detailed in the following
Privacy Impact Assessments: DHS/FEMA/PIA-012(a) Disaster Assistance Improvement Plain (DAIP) (Nov. 16, 2012); DHS/FEMA/PIA-027 National Emergency
Management Information System - Individual Assistance (NEMIS-IA) Web-based and Client-based Modules (June 29, 2012); DHS/FEMA/PIA-015 Quality Assurance
Recording System (Aug. 15, 2014). This includes sharing your personal information with federal, state, tribal, local agencies and voluntary organizations to enable individuals
to receive additional disaster assistance, to prevent duplicating your benefits, or for FEMA to recover disaster funds received erroneously, spent inappropriately, or through
fraud as necessary and authorized by routine uses published in DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records, 78 Fed. Reg. 25,282
(Apr.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 you from receiving FEMA
benefits.

1. APPLICANT NAME

2. DISASTER #

3. CURRENT MAILING
ADDRESS

4. REGISTRATION #

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 Temporary 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, permanent housing plan, current lease, rent receipts/
cancelled checks, and mortgage payment information.
7. Housing Costs (See Instructions for Definitions)

Expense

Pre Disaster
or
Prior Reported

Payment Cycle (How You Are Billed)
Current

Shade if Document
is Attached

Monthly
(1)

Quarterly
(4)

Bi-Annual
(6)

Annual
(12)

Other

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:
FEMA Form 010-0-12

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
INDIVIDUALS AND HOUSEHOLDS PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
8. Current Landlord Contact Information

NAME

PHONE NUMBER

9. Income Information for All Individuals 18 years of Age and Older Living in Current Temporary Residence
Gross Income
Name

Pre Disaster
or
Prior Reported

Current

Shade
if Document
is Attached

Pay Cycle
Weekly

Twice
Monthly

Monthly

Quarterly

Other

10. Permanent Housing Plan
I am a pre-disaster 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 pre-disaster 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 ability.
• 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

Date

Date Form Mailed to Applicant

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