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. 8/31/2022
(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

11. Home Damage

Seepage

Fire/Smoke/Soot/Ash

No

Yes

14. Current Location

Primary Home

15. Residence Type:

Travel Trailer

16, Primary Residence

Yes

Unknown

Home-Single/Duplex

No

17. Do You

No

Yes

13. Utilities Out

Mass Shelter

Other

Apt.

Condo/Townhouse

Other

Own

Rent

Family/Friends

Mobile Home

Other

Yes

12. Personal Property Damage

Hotel/Motel

Hail/Rain/Wind Driven Rain

Power Surge/Lightning
Tornado Wind

Ice/Snow

Sewer/Backup

Earthquake

No

Yes

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

No, due to disaster

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

19. Home/Personal Property Insurance
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 Caused By Disaster
Vehicle Information
Year

Make

Damaged?

Model

YES

NO

Full Coverage Insurance?

Drivable?
YES

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

Yes

No

Insurance Company Name

Liability Insurance?
YES

Registered?
YES

NO

NO

23. Emergency Needs
Gas, Medication, or Food

Shelter

Clothing

Durable Medical Equipment

24. Did you or anyone in your household use any type of mobility or assistive device such as a wheelchair, walker, cane, hearing aid, communication device, service animal, personal care attendant, or other
similarly medically-related devices or services that assist with disabilities or activities of daily living?
No
Yes
If yes, select all that apply:
Mobility:

Cognitive/Developmental

Hearing or Speech:

Disabilities/Mental Health:

Hearing Aid

TDD/TTY

Glasses

Sign Language
Interpreter

Text messaging and/or
other communication
device

White Cane

Wheelchair

Lift

Walker

Bath Chair

Personal Care Attendant

Cane

Personal Attendant

Other

Vision:

Other:
Braille or other accessible
communication device

Service Animal

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

Account Type:
Weekly

Bi-Weekly

Semi-Monthly

Quarterly

Yearly

30. Would you prefer to receive notification via traditional postal mail or E-mail?

Postal Mail

31. Would you like to receive additional updates via text message?

NO

YES

YES

NO

NO

Institution Name:

Income Refused

$

YES

Checking

Savings

(9 digits)

Routing No.

Account No.:
E-Mail

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

Spanish

33. Social Security Administration's Change of Address Request
When do you want this change to take effect?
34. Level of Damage to Home
or Personal Property:

Make the change effective

Minor damage but able to live in my home
Damage to Home/Personal Property and may not be able to live in my home

FEMA Form 009-0-1, July 12

Damage to Home/Personal Property requires
major repairs. Not able to live in home

REPLACES ALL PREVIOUS FEMA Form 90-69

My home was destroyed
Unknown

35. Comments

36. FEMA Representative

Application/Registration for Disaster Assistance Instructions
1.
2.
3.
4.
5.
6.

Enter the last name, first name, and middle initial of the application. Jr., Sr., etc. follow the last name.
Enter the language that the applicant speaks. If the applicant speaks English, leave blank.
Enter the date of birth of the applicant.
Enter the applicant's social security number (SSN). If the applicant does not provide a SSN, processing of the applicant may be delayed.
Enter e-mail address (if available).
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. Select the level of damage that best matches applicant's situation.
35. Enter any comments
36. Enter name of the FEMA representative filing out form.
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.
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 St. SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0002) NOTE: Do not send
your completed form to this address.

It is not necessary to complete grayed fields.