Form FEMA Form 140-003d FEMA Form 140-003d Authorization for the Release of Information Under the P

U.S. Department of Homeland Security

FEDERAL EMERGENCY MANAGEMENT AGENCY

AUTHORIZATION FOR THE RELEASE OF INFORMATION UNDER THE PRIVACY ACT
The purpose of this form is to allow you to direct the Department of Homeland Security/Federal Emergency
Management Agency (FEMA) to release information collected for your disaster assistance application to any entity
you choose. In accordance with the Privacy Act (PL 93-579) passed by Congress in 1974, FEMA cannot release
your information without your written consent (or an exception provided by law). Please return the completed form
to your FEMA point of contact or:
Mail to:
FEMA
P.O. Box 10055
Hyattsville, MD 20782-8055

Fax to:
800-827-8112
Attn: FEMA

Upload to:
www.DisasterAssistance.gov

Click “Check Status” on the Home Page
and follow the instructions

IMPORTANT: You are not obliged to give anyone access to information regarding you, but failure to
provide the information requested on this form may make it more difficult for FEMA to share your
information with other disaster relief entities to assist you.

Your Full Name (Last, First, MI)

Place of Birth (City, State/Province, Country)

Born At:

FEMA Applicant Number (OPTIONAL)

On:

Date of Birth
(mm-dd-yyyy)

SECTION A (OPTIONAL)
I authorize FEMA to release information selected in Section B below to the following individuals:
Name (Last, First)

Telephone
Number

Address

Relationship

Name (Last, First)

Telephone
Number

Address

Relationship

Name (Last, First)

Telephone
Number

Address

Relationship

SECTION B
I authorize FEMA to release to the individuals in Section A and/or the entities in Section C below the following information:
YES

NO
My case file, including inspection reports, amounts of awards, contact information, banking information, Social
Security Number, etc. (Cross out information you do not want to share or list under "Other" and check NO.)
My contact information, including address, phone number, e-mail address, work contact information, FEMA
application number, etc. (Cross out information you do not want to share or list under "Other" and check NO.)
Other:

FEMA Form Number

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SECTION C (OPTIONAL)
If additional disaster resources may be available to me, or if other persons request information regarding my
case, I authorize the information listed in Section B above to be released to:
YES

NO

State agencies offering disaster assistance
Local, Regional, State or National Voluntary Organizations Active in Disaster (NVOAD) and their partners
Members of Congress and their staff
Media representatives
Other:

This verification of identity and authorization to release records is made pursuant to and consistent with 28
U.S.C. § 1746. I declare under penalty of perjury under the laws of the United States that all of my information
on this form is true and correct. This authorization to release records expires one year from the date of signing.

Signature of the Applicant

Current Address

Print Your Name

Date (mm-dd-yyyy)

PRIVACY ACT STATEMENT
The primary purpose for soliciting this information is to establish your identity and your consent to share your information.
FEMA is committed to ensuring that any personal information received is safeguarded against unauthorized disclosure. The data you provide is
subject to the provisions of the Privacy Act (5 U.S.C. 552a). This means that FEMA will not disclose the information you provide unless you have
given us written authorization to do so, or unless the disclosure is otherwise permitted under the provisions of the Act or in accordance with our
routine uses published in Title 6, Part 5 of the Code of Federal Regulations. The information written on this form may be made available as a routine
use to other government agencies for law enforcement and administrative purposes.

FEMA Form Number

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