Narrative of Changes Table
The purpose of the Narrative of Changes Table is to demonstrate changes to a collection since the previous approval.
Collection Title: Disaster Assistance Registration
OMB Control No.: 1660 – 0002
Current Expiration Date: 8/31/2022
Collection Instrument(s):
FEMA Form 009-0-1 (English) Paper, Disaster Assistance Registration
Location
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Current version |
Proposed Revision |
Justification |
1. |
Name of Applicant (last, first, MI)__________
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Prefix □ Mr. □ Ms.
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Added to match Tele-registration/Internet RI script. Appropriate title is necessary to properly address correspondence.
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2. |
Language__________
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Applicant Name (last, first, MI)__________
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Question order adjusted.
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3. |
Date of Birth |
Language__________ |
Question order adjusted.
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4. |
Applicant Social Security No. __________ |
Applicant Social Security No. __________
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Question order adjusted.
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5. |
Email__________ |
Date of Birth__________ |
Question order adjusted.
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6. |
Damaged Phone #__________Alt Damaged Phone#__________ Note:_________ |
Email__________ |
Question order adjusted. |
7. |
Current Phone #__________ Alternate Cell Phone No. Note: __________ |
Do you have a disability or language need that requires an accommodation to interact with FEMA staff and/or access FEMA programs? □ Yes □ No
If Yes, what do you need? (select all that apply)
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Accommodation question added per OER/ODIC to capture applicants with disabilities or people with limited English proficiency who may self-identify and need additional assistance accessing FEMA programs. |
8. |
Damaged Property Address__________No. __________ Street__________ Apt/Lot__________ City__________ State__________ Zip__________ County__________
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Do you or anyone in your household have a disability that affects your ability to perform activities of daily living or requires an assistive device? (NOTE: An assistive device can include wheelchair, walker, cane, hearing aid, communication device, service animal, personal care attendant, oxygen, dialysis, etc.) □ Yes □ No
□ Mobility □ Cognitive/Developmental Disabilities/Mental Health □ Hearing/Speech □ Vision□ Self-Care □ Independent Living □ Other___________□ Prefer Not to Answer
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Disability-related questions revised per OER/ODIC at an attempt at clarity and to provide more comprehensive response options. Question order adjusted. |
9. |
Mailing Address□ Same as Damaged Address No. __________ Street__________ Apt/Lot__________ City__________ State__________ Zip__________
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Did you have any disability-related assistive devices or medically required equipment/supplies/support services damaged, destroyed, lost, or disrupted because of the disaster? □ Yes □ No
If Yes, select all that apply:
Other_____________
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Disability-related questions revised per OER/ODIC at an attempt at clarity and to provide more comprehensive response options. Question order adjusted. |
10. |
Cause of Damage□ Flood □ Fire/Smoke/Soot/Ash □ Seepage □ Power Surge/Lightning □ Hail/Rain/Wind Driven Rain □ Earthquake □ Sewer/Backup □ Ice/Snow □ Tornado Wind □ Other____________
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Damaged Dwelling Phone No.__________Cell Phone No._________ |
Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
11. |
Home Damage□ Yes □ No □ Unknown
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Current Phone No.__________ Alternate Phone No.__________ Note: __________
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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12. |
Personal Property Damage□ Yes □ No |
Damaged Dwelling Address__________No. __________ Street__________ Apt/Lot__________ City__________ State__________ Zip__________ County__________
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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13. |
Utilities Out□ Yes □ No |
Do You: □ Own □ Rent
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Question order adjusted. |
14. |
Current Location□ Primary Home □ Hotel/Motel □ Family/Friends □ Mass Shelter □ Other__________
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Mailing Address□ Same as Damaged Address No. __________ Street__________ Apt/Lot__________ City__________ State__________ Zip__________
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Question order adjusted. |
15. |
Residence Type□ Travel Trailer □ Mobile Home □ Home-Single/Duplex □ Apt. □ Condo/Townhouse □ Other
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Damage Type□ Flood □ Hurricane/Hail/Rain/Wind Driven Rain □ Power Surge/Lightning □ Seepage □ Sewer Backup □ Tornado/Wind □ Earthquake □ Fire/Lava Flow/Ash □ Ice/Snow □ Other____________
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
16. |
Primary Residence□ Yes □ No
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Home Damage?□ Yes □ No □ Unknown
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Question order adjusted. |
17. |
Do You□ Own □ Rent |
Personal Property Damage (not including vehicles)?□ Yes □ No □ Unknown
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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18. |
Is your home accessible?□ Yes □ No, due to mandatory evacuation □ No, due to disaster
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Utilities Out 5 days or more?□ Yes □ No |
Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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19. |
Home/Personal Property Insurance Insurance Type__________ Insurance Company Name__________ □ I have no insurance for my home or personal property
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New or additional child care costs because of disaster? □ Yes □ No
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
20. |
Disaster Caused Expenses (for uninsured or underinsured expenses) Expense Type Medical Dental Funeral YES__________ NO__________ IF YES and have insurance, Insurance Company Name__________
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Level of Damage to Home or Personal Property: □ Minor damage but able to live in home □ Damage to Home/Personal Property and may not be able to live in home □ Damage to Home/Personal Property requires major repairs. Not able to live in home. □ Home was destroyed □ Unknown
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Question order adjusted. |
21. |
Vehicle Damage Caused By Disaster Vehicle Information Year__________ Make__________ Model__________ Damaged? YES__________ NO__________ Drivable? YES__________ NO__________ Full Coverage Insurance? YES__________ NO__________ Liability Insurance? YES__________ NO__________ Insurance Company Name__________ Registered? YES__________ NO__________
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Current Location?□ My Home □ Family/Friends □ Hotel/Motel □ Mass Shelter □ Church/House of Worship □ Homeless □ FEMA Provided Unit □ New Permanent Rental □ New Temporary Rental □ Purchased New Home □ Place of Employment □ RV/Camper □ Secondary Residence □ My Vehicle □ Tent |
Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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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? □ Yes □ No
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Type of Home?□ Home-Single/Duplex □ Mobile Home □ Townhouse □ Condo □ Apartment □ Travel Trailer □ Assisted Living Facility □ Boat □ College Dormitory □ Correctional Facility □ Military Housing □ Other__________
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
23. |
Emergency Needs□ Gas, Medication, or Food □ Shelter □ Clothing □ Durable Medical Equipment
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Primary Residence?□ Yes □ No
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Question order adjusted. |
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? □ Yes □ No
If yes, select all that apply: Mobility: □ Wheelchair □ Walker □ Cane □ Lift □ Bath Chair □ Personal Attendant
Cognitive/Developmental Disabilities/Mental Health: □ Personal Care Attendant □ Other_______________
Hearing or Speech: □ Hearing Aid □ Sign Language Interpreter □ TDD/TTY □ Text messaging and/or other communication device
Vision: □ Glasses □ White Cane □ Service Animal □ Braille or other accessible communication device □ Magnifier □ Other:________________
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Currently able to get to your home?□ Yes □ No, due to mandatory evacuation □ No, due to damages to roads or bridges in the area
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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25. |
Occupants living in primary residence at time of disaster Last Name__________ First Name__________ MI__________ Relationship__________ Social Security Number (Applicant First, Please) __________ Age__________ Dependent? YES__________ NO__________
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Home/Personal Property Insurance Insurance Type__________ Insurance Company Name__________ □ I have no insurance for my home or personal property |
Question order adjusted. |
26. |
BUSINESS DAMAGESSelf Employment is primary income? □ YES □ NO
Own/Represent a business or rental property affected by disaster? □ YES □ NO
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Disaster Related Expenses (uninsured or under-insured) Expense Type Medical Dental Funeral YES__________ NO__________ Insurance Company Name (if insured)__________
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
27. |
Number of claimed dependents__________
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Disaster Related Vehicle Damage Vehicle Information Year__________ Make__________ Model__________ Damaged? YES__________ NO__________ Drivable? YES__________ NO__________ Comprehensive Insurance? YES__________ NO__________ Liability Insurance? YES__________ NO__________ Insurance Company Name__________ Registered? YES__________ NO__________
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
28. |
Combined family pre-disaster gross income $__________ □ Weekly □ Bi-Weekly □ Semi-Monthly □ Quarterly □ Yearly □ Income Refused
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Emergency Needs□ Food, Medication, Durable Medical Equipment, or Gas □ Shelter □ Clothing
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
29. |
Electronic Funds Transfer□ YES □ NO Institution Name: __________ Account Type: □ Checking □ Savings □ Routing No_____(9 digits) Account No.:__________
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Persons living in your home at time of disaster Last Name__________ First Name__________ MI__________ Relationship__________ Social Security Number (App and Co-App Only) __________ Age__________ |
Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
30. |
Would you prefer to receive notification via traditional postal mail or E-mail? □ Postal Mail
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Business DamagesHousehold’s source of income is self-employment? □ Yes □ No
Own a business or rental property affected by the disaster? □ Yes □ No
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
31. |
Would you like to receive additional updates via text message? □ YES □ NO
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No. of Dependents (including yourself)_________ |
Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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32. |
In which language would you like to receive letters? □ English □ Spanish
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Family’s pre-disaster income before taxes are deducted $__________ □ Income not available
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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33. |
Social Security Administration’s Change of Address Request When do you want this change to take effect?__________ Make the change effective__________
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Electronic Funds Transfer□ Yes □ No Bank/Financial Institution Name:__________ Account Type: □ Checking □ Savings □ Routing No._____(9 digits) Account No.:__________
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
34. |
Level of Damage to Home or Personal Property: □ Minor damage but able to live in my home □ Damage to Home/Personal Property and may not be able to live in my home □ Damage to Home/Personal Property requires major repairs. Not able to live in home. □ My home was destroyed □ Unknown
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Correspondence language? □ English □ Spanish
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
35. |
Comments__________
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Traditional postal mail or electronic notification? □ Postal Mail
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.
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36. |
FEMA Representative__________
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Receive text messaging updates? □ Yes □ No
Mobile Phone No.:__________
Agree to text messaging terms? □ Yes □ No
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Question order adjusted. Question re-worded to match Tele-registration/Internet RI script. |
37. |
N/A |
Comments__________
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Question order adjusted. |
38. |
N/A |
FEMA Representative_________
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Question order adjusted. |
Page 2. 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. 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.
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Bentley, Alyssa |
File Modified | 0000-00-00 |
File Created | 2021-03-02 |