Form 009-0-1 Application / Registration for Disaster Assistance

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

REC. #

2. Language

1. Name of Applicant (last, first, MI)
6. Damaged Phone #

DR #

O.M.B. No. 1660-0002
Exp. May 31, 2014
(see reverse side)

APPLICATION/REGISTRATION FOR DISASTER
ASSISTANCE
3. Date of Birth

APP. DATE

4. Applicant Social Security No.

7. Current Phone #

Alt Damaged Phone#

Loss Date

5. Email

Alternate Cell Phone No.

Note:
8. Damaged Property Address

No.

Street

Apt/Lot

City.

State

9. Mailing Address

No.

Street

Apt/Lot

City.

State

Zip

County
Zip

Same as Damaged Address
10. Cause of Damage

Flood

Fire/Smoke/Soot/Ash

Earthquake
11. Home Damage

No

Yes

14. Current Location

Primary Home

15. Residence Type:

Travel Trailer

16, Primary Residence

Yes

Home-Single/Duplex

No

17. Do You

Yes

13. Utilities Out

Mass Shelter

Other

Apt.

Condo/Townhouse

Other

Own

Rent

Family/Friends

Mobile Home.

No

Yes

12. Personal Property Damage

Hotel/Motel

Other

Tornado Wind

Ice/Snow

Unknown

Hail/Rain/Wind Driven Rain

Power Surge/Lightning

Seepage

Sewer/Backup

No

Yes

18. Is your home accessible?
No, due to mandatory evacuation

19. Home/Personal Property Insurance

No, due to disaster

20. Disaster Related Expenses (for uninsured or underinsured expenses)

Insurance Type

Insurance Company Name

Expense Type

YES

NO

IF YES and have insurance, Insurance Company Name

Medical
Dental
Funeral
I have no insurance for my home or personal property
21. Vehicle Damage due to Disaster
Vehicle Information
Year

Make

Damaged?

Model

YES

NO

Drivable?
YES

Comprehensive Insurance?
YES

NO

22. As a result of the disaster, do you have new or additional child care costs
or has your household income been reduced, increasing your financial burden
to pay for child care?

NO

No

Yes

Insurance Company Name

Liability Insurance?
YES

Registered?
YES

NO

NO

23. Emergency Needs
Shelter

Food

Clothing

24. Special Needs: Did you, your co-applicant, or any dependents have help or support doing things like walking, seeing, hearing, or taking care of yourself before the disaster and have you lost that help or
support because of the disaster?
YES
NO
If Yes, Select all that apply. Mobility, such as:
(Select all that apply)

Wheelchair

Walker

Cane

Lift

Bath Chair

Personal Care Attendant, etc.

Cognitive/Developmental Disabilities/Mental Health, such as: Personal care attendant, etc.
Hearing or speech, such as: Hearing aid, sign language interpreter, TDD/TTY,
text messaging and/or other accessible communication device

Other

Vision, such as: Glasses, white cane, service animal, Braille, or other accessible communication device, magnifier
25. Occupants living in primary residence at time of disaster
Last Name

MI

First Name

Social Security Number
(Applicant First, Please)

Relationship

Age

Dependent?
YES
NO

26. BUSINESS DAMAGES
Self Employment is primary income?

YES

NO

Own/Represent a business or rental property affected by disaster?

27. Number of claimed dependents

29. Electronic Funds Transfer

28. Combined family pre-disaster gross income

Income Refused

Checking

Account Type:
Bi-Weekly

Semi-Monthly

Quarterly

Yearly

YES

Postal Mail

E-Mail

34. Comments

FEMA Form 009-0-1, July 12

NO

(9 digits)

Routing No.

32. In which language would you like to receive letters?
English

NO

33. Social Security Administration's Change of Address Request
When do you want this change to take effect?

Savings

Account No.:

30. Would you prefer to receive correspondence via traditional postal mail or E-mail notification?
31. Would you like to receive additional status notifications via text message?

YES

NO

Institution Name:

$
Weekly

YES

Make the change effective
35. FEMA Representative

REPLACES ALL PREVIOUS FEMA Form 90-69

Spanish

Application/Registration for Disaster Assistance Instructions
1. Enter the last name, first name, and middle initial of the application. Jr., Sr., etc. follow the last name.
2. Enter the language that the applicant speaks. If the applicant speaks English, leave blank.
3. Enter the date of birth of the applicant.
4. Enter the applicant's social security number (SSN). If the applicant does not provide a SSN, processing of the applicant may be delayed.
5. Enter e-mail address (if available).
6. Do NOT include a beeper/pager number in any of the phone number fields. Damaged Phone number: enter the phone number used in the applicant's home at the time of the
disaster even if the number is currently working.
7. Current Phone No. Enter the current phone number where the applicant can be reached. Alternate/Cell Phone No.: enter a work phone number or the phone number of a friend,
relative, or neighbor that FEMA can use to leave a message for the applicant. Note: include extension number (if available).
8. Enter the full physical street address at which the damage occurred. Do not enter a P.O. or general delivery address.
9. Enter the applicant's mailing address. It may or may not be the same as the Damaged Property Address or where the applicant is now living. The Mailing Address may be a post
office or general delivery address. If it is the same as the damaged property address, check the box for the same.
10. Check Cause of Damage (more than one cause may be checked). Other causes of damage may include explosion, drought, and riot. If more than the home was damaged (e.g., auto
was flooded), please describe in the Comments section in item No. 34.
11. If the applicant has damage to the home (e.g., electrical, heating, floors, walls, ceilings, and foundation), check Yes. If home damage is unknown, check Unknown.
12. If the applicant had Personal Property Damage, e.g., appliances, clothing, and/or furniture), check Yes.
13. If the applicant's utilities are not working (out), check "Yes." Utilities may include sewer, water, gas, electricity, and/or heating.
14. Check the current Location where the applicant is living.
15. Check the type of residence that was damaged (e.g., Travel Trailer, Mobile Home, House-Single/Duplex, etc.). Other may include, for example, homeless or RV.)
16. If the person lived in the home more than six months of the year, or the applicant lists it as the address of his/her Federal Tax Return, or the applicant files a homestead exemption,
or the applicant uses it as a voter registration address, check "Yes."
17. If the applicant is named on the deed, or the applicant maintains the home and pays the taxes but pays no rent, or the applicant has lifetime occupancy rights while not holding
legal title to the home, check Own. Check "Rent" if the applicant does not meet any of the above ownership criteria, even if the applicant pays no rent.
18. If the home is Accessible after the disaster, check "Yes." Inaccessible may include disruption or destruction of transportation routes or other obstructions that prevent the applicant
from gaining entry to the damaged home. If the applicant is unable to enter the home, determine if it's Due to the Disaster, or Due to Mandatory Evacuation and check appropriately.
19. List the type of insurance that the applicant held at the time of the disaster for the home and/or personal property, including but not limited to sewer backup, earthquake. Include
the name of the insurance company. If no insurance, check I have no insurance for my home or personal property.
20. If the applicant incurred a Medical, Dental, Funeral, and/or Moving Storage Expense related to the disaster, check "Yes." Under Insurance company, provide the name of applicant's
insurance company if they had insurance for that expense.
21. Enter all vehicles for the household (regardless of condition) and their year, make, and model. If the applicant or one of the applicant's dependents owns a vehicle(s) that was
damaged by the disaster, check "yes,." Also, check "Yes" for the vehicles that are drivable,. Check "Yes" if the listed vehicle(s) has Comprehensive and/or Liability Insurance, and
if the vehicle(s) is registered. Enter the name of the insurance company if applicant has insurance. If more space is needed, use the space in Item #29.
22. If the applicant had new or additional child care cost, or household income reduced and is causing a financial burden to pay child care check yes .
23. If the applicant has Emergency Needs (e.g, food, clothing, shelter), check the appropriate box for type of need.
24. Question relates to special needs. The Americans with Disabilities Act (ADA) defines a disability as "a physical or mental impairment that substantially limits one or more of the
major life activities of such individual." 42 USC 12102(2) (A). If the registrant or household member has such a disability and was affected by the disaster, please mark all of the
areas of disability that apply.
25. List information for the applicant and all other persons/dependents who consider the home to be their primary residence at the time of the disaster, whether or not they are related
to the applicant. It is important that the applicant's and co-applicant's SSN is included. Answer if they are a dependent or not.
26. SELF EMPLOYMENT IS PRIMARY INCOME? Check appropriately. OWNS/REPRESENTS BUSINESS OR RENTAL PROPERTY? Check appropriately.
27. Enter the number of claimed dependents as listed on the applicant's Federal Tax Return.
28. Enter the combined family pre-disaster gross Income. (This is the amount of income before any deductions, and may include money from employment, Social Security, retirement,
welfare, child support, stocks, interest, annuities, and savings or assistance from family and friends. It does not include food stamps or HUD Section 8 assistance.) Check the
appropriate frequency of pay (weekly, bi-weekly, monthly, semi-monthly, quarterly, or yearly). If income refused, check appropriate box.
29. If the applicant would like FEMA to automatically transfer assistance into their checking or savings account, check "Yes" next to Electronic Funds Transfer. Enter the name of the
applicant's financial institution. Enter the applicant's 9-digit routing no. (The routing no. is the 9-digit number that appears in the lower left hand corner of the check.) Indicate the
applicant's account type by marking the Checking or Savings box. Enter the applicant's account no. (The account number can be found at the center bottom of a check
immediately after the routing number, or can be found on a savings or checking account statement.) NOTE: Applicant name must be on the account.
30. Check how the applicant would like to receive correspondence. Postal Mail or E-mail
31. Select the language the applicant would like to receive correspondence. English or Spanish
32. If applicant would like to receive status updates via text message. Confirm Alternate Cell phone.
33. If applicable, enter Social Security Administration's Change of Address Request
34. Enter any comments
35. Enter name of the FEMA representative filing out form.
PAPERWORK BURDEN DISCLOSURE NOTICE
009-0-1(Paper Application)
Public reporting burden for this data collection is estimated to average 18 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, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0002) NOTE: Do not send your
completed form to this address.

It is not necessary to complete grayed fields.

PRIVACY NOTICE
AUTHORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records within this system under the authority of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act (the Stafford Act), Pub. L. No. 93-288, as amended, 42 U.S.C. §§ 5121-5207; 6 U.S.C. §§ 776-77, 795; the
Debt Collection Improvement Act of 1996, 31 U.S.C. §§ 3325(d), 7701(c)(1); the Government Performance and Results Act, Pub. L. No. 103-62, as
amended; Reorganization Plan No. 3 of 1978; Executive Order 13411, “Improving Assistance for Disaster Victims,” August 29, 2006; and Executive Order
12862 “Setting Customer Service Standards,” September 11, 2003, as described in this notice.
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 internally within FEMA for quality assurance purposes and used to
assess FEMA's customer service to disaster assistance applicants. FEMA collects the social security number (SSN) to verify an applicant's identity and to
prevent a duplication of benefits.
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
permitted by 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.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: The disclosure of information, including the SSN, on this form is voluntary; however,
failure to provide the information requested may delay or prevent the individual from receiving disaster assistance.
Phone Script:
“We are required to provide you with the following Privacy Act Statement.
The Privacy Act of 1974 protects your rights as to how FEMA uses and shares your information.
The Stafford Act and other authorities allow FEMA to collect this information to determine eligibility and administer financial assistance as a result of a
Presidentially-declared major disaster or emergency. FEMA may share your information outside of FEMA with entities such as with States, tribes, local
governments, voluntary organizations, and other organizations in accordance with published routine uses. FEMA shares this information to enable you to
receive additional disaster assistance, or for FEMA to recover disaster funds received erroneously, spent inappropriately, or through fraud and as necessary
to prevent a duplication of benefits and to prevent future disaster losses.
FEMA may record phone calls for internal quality assurance purposes. Furnishing your SSN and other requested information is voluntary, however, failure
to provide may delay or prevent you from receiving assistance.”
If you knowingly make false statements to obtain disaster aid, it is a violation of federal and State laws.

Automated Message:
“We are required to provide you with the following Privacy Act Statement.
The Privacy Act of 1974 protects your rights as to how FEMA uses and shares your information.
The Stafford Act and other authorities allow FEMA to collect this information to determine eligibility and administer financial assistance as a result of a
Presidentially- declared major disaster or emergency.
FEMA may share your information outside of FEMA with entities such as with States, tribes, local governments, voluntary organizations, and other
organizations in accordance with published routine uses. FEMA shares this information to enable you to receive additional disaster assistance, or for FEMA
to recover disaster funds received erroneously, spent inappropriately, or through fraud and as necessary to prevent a duplication of benefits and to prevent
future disaster losses.
FEMA may record phone calls for internal quality assurance purposes. Furnishing your SSN and other requested information is voluntary, however, failure
to provide may delay or prevent you from receiving assistance.”
If you knowingly make false statements to obtain disaster aid, it is a violation of federal and State laws.