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pdfDEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
OMB No.: 1660-NEW
Expiration Date: XX-XX-XXXX
DIRECT ASSISTANCE RECERTIFICATION WORKSHEET
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 20 minutes per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form.
This collection of information is mandatory. You are not required to respond to this collection of information unless a valid OMB control number
appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing
this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C
Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-NEW). Please do not send your completed survey to the above
address.
PRIVACY ACT STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part
206.117.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of advising FEMA Individual Assistance applicants of the
requirements to occupy temporary housing units, of the requirements for final sales of the unit if FEMA offers a sale program for its temporary
housing units as part of its direct housing program under a Presidentially-declared disaster.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974,
as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster
Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (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 the individual from receiving the requested disaster-related temporary housing assistance.
1. DISASTER #:
2. APPLICANT NAME:
3. REGISTRATION #:
4. PRE-DISASTER HOUSING STATUS: 5. ADDRESS OF UNIT:
OWNER
6. # OF BEDROOMS IN UNIT:
RENTER
1
7. PARK/SITE NAME:
9a. TARGET MOVE-OUT DATE:
12. SITE TYPE:
CS
3
8. CURRENT PHONE #:
9. LEASE/MOVE-IN DATE:
PS
2
GS
Oth
MLRP
10. LOT #:
11. SITE CONTROL #:
13. RECERTIFICATION DATE:
14. LOT TYPE:
DL
15. VIN # (Applicable to MHU): 16. BARCODE # (Applicable to MHU): 17. RECERTIFICATION VISIT #: 17a. DATE OF LAST RECERT VISIT:
AUTH
18. Persons Living in Unit
NAME
FEMA FORM 009-0-134 (9/14)
REL
SEX AGE YES NO
19. Household Income of all Applicants 18 Years of Age or Older
a. PRE-DISASTER INCOME
REPLACES FEMA Form 90-139
Initials
b. POST-DISASTER INCOME
Initials
Page 1 of 6
21. FMR FOR COUNTY OF DAMAGED DWELLING:
20. HH BEDROOM REQUIREMENT:
22. HOUSING COSTS (OWNERS)
*Pre-Disaster Mortgage:
*Post-Disaster Mortgage:
Pre-Disaster Utilities:
Post-Disaster Utilities:
*Includes Mortgage, Property Taxes, Homeowners insurance
22a. HOUSING PLAN PROGRESS FOR OWNERS
HAVE THE REPAIRS BEGUN?
YES
NO
IF SO, HAS A CONTRACTOR BEEN HIRED OR VOLUNTEERED?
CONTRACTOR'S NAME:
PERMITS OBTAINED?
NO
NO
DATE:
CONTRACTOR'S ADDRESS:
DELAY IN COMPLETING THE REPAIRS TO THE DDA?
CONTRACTOR'S PHONE #:
DELAY IN PURCHASING A HOME?
YES
YES
YES
NO
YES
NO
IF YES, PLEASE
SPECIFY:
PERCENTAGE OF
REPAIRS COMPLETE:
22b. HOUSING COSTS (RENTERS ONLY)
Pre-Disaster Rent:
FEMA FORM 009-0-134 (9/14)
Pre-Disaster Utilities:
REPLACES FEMA Form 90-139
Page 2 of 6
DIRECT ASSISTANCE RECERTIFICATION WORKSHEET
22c. HOUSING PLAN PROGRESS FOR RENTERS
RENTAL RESOURCES OFFERED
YES
NUMBER OF RENTAL RESOURCES OFFERED:
NO
DID THE APPLICANT REFUSE THE RENTAL RESOURCE?
YES
NO
IF YES, PLEASE SPECIFY
THE REFUSAL REASON:
23. REALISTIC PERMANENT HOUSING PLAN
23a. PROJECTED DATE FOR
HOUSING PLAN COMPLETION
RENT A RENTAL RESOURCE
PURCHASE A HOME
REPAIR/REBUILD DAMAGED DWELLING
MOVE IN WITH FAMILY/FRIENDS
PURCHASE FEMA THU (APPLICABLE IF SALES/
DONATIONS PROGRAM IS ACTIVATED)
YES
23b. HOUSING PLAN DOCUMENTATION VERIFIED?
NO
IF SO, PLEASE SPECIFY
THE VERIFIED
DOCUMENTATION:
PRE-DISASTER HUD/SECTION 8:
YES
NO
VAL ASSISTANCE
YES
NO
STATE HOUSING/GRANT ASSISTANCE PROGRAM:
YES
NO
DHAP REFERRAL:
YES
NO
COMMENTS:
RENTAL RESOURCE #1:
RENTAL RESOURCE #2:
Address:
Address:
Contact's Name:
Contact's Name:
Type of Rental Resource:
Type of Rental Resource:
Number of Bedrooms:
Number of Bedrooms:
Monthly Rent:
Monthly Rent:
RENTAL RESOURCE #3:
RENTAL RESOURCE #4:
Address:
Address:
Contact's Name:
Contact's Name:
Type of Rental Resource:
Type of Rental Resource:
Number of Bedrooms:
Number of Bedrooms:
Monthly Rent:
Monthly Rent:
24. FEMA RECERTIFICATION CASEWORKERS NAME:
24a. RECERTIFICATION RECOMMENDATIONS:
25. HOUSING GROUP SUPERVISOR SIGNATURE
APPROVED CONTINUED
APPROVED DATES
DENIED
FROM
25a. ELIGIBILITY/DENIAL REASONS:
DATE
TOTAL MONTHS:
TO
PROGAM ELIGIBILITY
MAJOR VIOLATION
VIOLATED PARK/SITE RULES
NOTES:
26. FOR SUPERVISOR USE ONLY
RECERTIFICATION APPROVED?
FEMA FORM 009-0-134 (9/14)
YES
NO
NUMBER OF MONTHS
REPLACES FEMA Form 90-139
1
2
3
Page 3 of 6
DIRECT ASSISTANCE RECERTIFICATION CHECKLIST
Applicant's Name:
Disaster #:
Registration #:
INTRODUCTION
Introduce your self and show the person your FEMA Identification.
Explain why you are there - to conduct a recertification.
Verify the identity of the person completing the recertification (applicant or co-applicant).
Verify Written Consent/Release of Information on file (ROI).
Verify the unit number (Applicable to MHU).
Provide a scope of the Recertification.
Explain what you will be doing today.
RECERTIFICATION WORKSHEET
Complete Worksheet.
If a copy of income and mortgage information is not provided by applicant, take picture of the original document.
Document the housing plan information provided during each recertification visit i.e. lease, housing searches, progress of repairs
to damaged dwelling address.
Verify Written Consent/Release of Information on file (ROI).
Make appropriate contacts to contractors to confirm progress of repairs. Make contacts to rental resources to confirm availability.
Offer rental resources when appropriate.
Conduct a follow-up with the applicant to ensure rental resources provided were contacted.
REPAIR PROGRESS CHECKLIST (OWNERS ONLY)
Inform applicant of the need to evaluate what repairs have been completed.
Document and evaluate the repairs and damage to the dwelling which has rendered the home inhabitable (essential repairs only).
If necessary, go to damaged dwelling and record outside condition (e.g., does it look like repair work has began). Record the
observations in Comments section.
If unsure about the state of repairs, ask the applicant if it was damaged or has already been repaired.
Explain to applicant that you are only recording what you observe.
Contact contractor on the progress and completion of the repairs to the pre-disaster damaged dwelling. Confirm any delays on the
progress and completion of the repairs (if applicable).
Complete Checklist.
PICTURE PROTOCOL
Take a picture of every damaged room (First Recert Only).
Take a picture of each room that is still being repaired. Picture should capture the damage to that specific room.
Take a picture of the exterior damages that are still in the repair phase; essential to the habitability of the dwelling.
RECAP
Document the condition (e.g., maintenance issues, interior, exterior damages and furnishings) of the unit on the Temporary
Housing Unit Inspection Report (FF 90-13).
Document the applicant's NEMIS file with all recertification information documented as each visit.
Inform the applicant of your recommendation for recertification and what was observed during this visit.
Inform the applicant he/she will be notified within 7 - 14 days of their eligibility for recertification.
Provide FEMA Contact Numbers (Helpline, Maintenance, Sales, etc.).
Remind Applicant to Update FEMA if contact information changes, e.g., phone number.
FEMA FORM 009-0-134 (9/14)
REPLACES FEMA Form 90-139
Page 4 of 6
1. INSPECTION DATE:
REPAIR PROGRESS CHECKLIST (FOR PRE-DISASTER OWNERS ONLY)
2. RECERTIFICATION #:
3. APPLICANT'S NAME:
4. REGISTRATION ID #:
5. DISASTER #:
7. DAMAGED DWELLING DESCRIPTION:
6. DAMAGED DWELLING ADDRESS:
Apartment
House-Single/Duplex
Boat
Mobile Home
Condo
Townhouse
Travel Trailer
Other
8. CONDITION OF ROOMS, INTERIOR, & EXTERIOR AT THE TIME OF RECERTIFICATION
Instructions: Take basic pictures of essential rooms and damages that continue to render the home unlivable.
RP=Repairs Completed RB=Repairs Begun RN=Repairs Not Started UD=Undamaged N/A=Non Applicable
Picture
Picture
Exterior Damages
Taken Condition
Room
Taken Condition
Room
Living Room (LR)
Bedroom 1 (BR1)
Bathroom 1 (BA1)
Ceiling
Ceiling
Toilet
Floor
Floor
Basin
Outlet/Switches
Outlet/Switches
Tub/Shower
Wall
Wall
Faucets/Plumbing
Window
Window
Walls
Picture
Taken Condition
Kitchen (KIT)
Bedroom 2 (BR2)
Window
Cabinets
Ceiling
Cabinet
Ceiling
Floor
Bathroom 2 (BA2)
Faucets/Plumbing
Outlet/Switches
Toilet
Floor
Wall
Basin
Outlet/Switches
Window
Tub/Shower
Range
Bedroom 3 (BR3)
Faucets/Plumbing
Refrigerator
Ceiling
Walls
Sink
Floor
Window
Wall
Outlet/Switches
Cabinet
Window
Wall
Bathroom 3 (BA3)
Utilities
Window
Toilet
Furnace
Bedroom 4 (BR4)
Basin
HVAC
Ceiling
Tub/Shower
Water Heater
Floor
Faucets/Plumbing
Utilities
Outlet/Switches
Walls
Gas
Wall
Window
Electric
Window
Cabinet
Water
Exterior Walls
Hallway (HWY)
EWL
Other (OTH)
Debris that hinders
repairs or access to DD
Walls
Outlet/Switches
EWR
EWF
Utility Connections
(septic, water, electric)
EWB
Wall Framing
9a. COMMENTS
PLACED IN NEMIS?
YES
NO
9. COMMENTS
10. NAME OF PERSON PRESENT DURING RECERTIFICATION:
12. FEMA RECERTIFICATION STAFF NAME:
FEMA FORM 009-0-134 (9/14)
11. RELATIONSHIP TO APPLICANT (i.e. App, Co-App, Occupant):
13. FEMA RECERTIFICATION STAFF SIGNATURE:
REPLACES FEMA Form 90-139
14. DATE:
Page 5 of 6
CONTINUED ASSISTANCE
PICTURE NAMING CONVENTION
ME
-
First 2 letters of
Applicant's last name
123456789
-
9 Digit FEMA
Registration ID#
LR
-
080309
Room
Identifier
Date
MM/DD/YY
Room Identifier Legend
EXTERIOR
INTERIOR ANCILLARY SPACE
EWB: Exterior Wall Back
EWF: Exterior Wall Front
EWL: Exterior Wall Left
EWR: Exterior Wall Right
CRL: Crawlspace
BSM: Basement
FR: Family Room
HWY: Hallway
OTH: Other
UTM: Utility Room
WH
-
First 2 letters of
Applicant's last name
INTERIOR LIVING SPACE
BA1: Bathrooms (Numbering from closet or inside the master
bathroom to furthest away)
BR1: Bedrooms (Numbered from closet to master bedroom to
furthest away)
DR: Dining Room
KIT: Kitchen
LR: Living Room
123456789
- PSB -
9 Digit FEMA
Registration ID#
Document
Identifier
050109
Date
MM/DD/YY
Document Identifier Legend
INCOME
CURRENT HOUSING COSTS
PSB: Pay Stub
SSA: Social Security Statements
IST: Investment Statements (ex. Stocks, Mutual
Funds, Money Market Accounts)
UES: Unemployment Benefits Statement
RBS: Retirement Benefits Statement
OTR: Other Income Documents (ex. Bank
Statements, Deposit Slips, etc.)
FEMA FORM 009-0-134 (9/14)
MS 1-2: 1st and 2nd Mortgage Statement
PTR: Property Tax Receipt
HOI: Homeowners Insurance Statement or Declaration Page
GRT: Ground Rent
NOTE: Any Income or Current Housing Cost documentation will have
sensitive information such as Social Security numbers or Account
Numbers. This Information MUST be covered to protect Privacy and
Identity.
REPLACES FEMA Form 90-139
Page 6 of 6
| File Type | application/pdf |
| File Title | FEMA Form |
| File Modified | 2015-07-10 |
| File Created | 2015-07-10 |