NOC 009-0-1 (English)

NOC_009-0-1 (English).docx

Disaster Assistance Registration

NOC 009-0-1 (English)

OMB: 1660-0002

Document [docx]
Download: docx | pdf

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


Current version

Proposed Revision

Justification

1.

Name of Applicant (last, first, MI)__________


Prefix

□ Mr.

□ Ms.


Added to match Tele-registration/Internet RI script. Appropriate title is necessary to properly address correspondence.


2.

Language__________


Applicant Name (last, first, MI)__________


Question order adjusted.


3.

Date of Birth

Language__________

Question order adjusted.


4.

Applicant Social Security No. __________


Applicant Social Security No. __________


Question order adjusted.


5.

Email__________

Date of Birth__________

Question order adjusted.


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)

  • Sign language interpreter

  • CART (Communication Access Real-time Translation) (in person or remote)

  • Text messages to communicate

  • Assistive listening device

  • Braille

  • Large print

  • Face-to-face assistance (reader or writer)

  • Wheelchair access

  • Language other than English

    • Spanish – Español

    • Arabic – العربية

    • Haitian Creole – Kreyòl Ayisyen

    • Russian – Русский

    • Vietnamese – Tiếng Việt

    • Samoan – Sāmoa

    • Mandarin – 中文

    • Other_________

  • Other___________


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__________


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


If Yes, select all that apply:

□ Mobility

□ Cognitive/Developmental Disabilities/Mental Health

□ Hearing/Speech

Vision

□ Self-Care

□ Independent Living

Other___________

□ Prefer Not to Answer


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__________


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:

  • Power/manual wheelchair

  • Scooter

  • Prosthesis

  • Oxygen/respiratory equipment

  • Medical equipment that depends on electricity

  • Assistive technology device for hearing/vision, such as hearing aid, screen enlarging software, etc.

  • Personal-care devices such as shower bench, bedside commode, Hoyer lift, or lift chair

  • Environmental control/alerting devices

  • Adaptive van/vehicle

  • Walker/cane/crutches

  • Medication/medical supplies including adult diapers and catheters

  • Service animal

  • Personal assistance services/in-home care

  • Dialysis

Other_____________


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____________


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


Current Phone No.__________

Alternate Phone No.__________

Note: __________


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


12.

Personal Property Damage

□ Yes □ No

Damaged Dwelling Address__________

No. __________

Street__________

Apt/Lot__________

City__________

State__________

Zip__________

County__________


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


13.

Utilities Out

□ Yes □ No

Do You:

OwnRent


Question order adjusted.

14.

Current Location

□ Primary Home

□ Hotel/Motel

□ Family/Friends

□ Mass Shelter

□ Other__________


Mailing Address

□ Same as Damaged Address

No. __________

Street__________

Apt/Lot__________

City__________

State__________

Zip__________


Question order adjusted.

15.

Residence Type

□ Travel Trailer

□ Mobile Home

□ Home-Single/Duplex

□ Apt.

□ Condo/Townhouse

□ Other


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____________


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.

16.

Primary Residence

□ Yes □ No


Home Damage?

□ Yes □ No □ Unknown


Question order adjusted.

17.

Do You

□ Own □ Rent

Personal Property Damage (not including vehicles)?

□ Yes □ No □ Unknown


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


18.

Is your home accessible?

□ Yes

□ No, due to mandatory evacuation

□ No, due to disaster


Utilities Out 5 days or more?

□ Yes □ No

Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


19.

Home/Personal Property Insurance

Insurance Type__________

Insurance Company Name__________

□ I have no insurance for my home or personal property


New or additional child care costs because of disaster?

□ Yes □ No


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__________


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


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__________


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.


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


Type of Home?

□ Home-Single/Duplex

□ Mobile Home

□ Townhouse

□ Condo

□ Apartment

□ Travel Trailer

□ Assisted Living Facility

□ Boat

□ College Dormitory

□ Correctional Facility

□ Military Housing

□ Other__________


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


Primary Residence?

□ Yes □ No


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:________________


Currently able to get to your home?

□ Yes

□ No, due to mandatory evacuation

□ No, due to damages to roads or bridges in the area


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


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__________


Home/Personal Property Insurance

Insurance Type__________

Insurance Company Name__________

□ I have no insurance for my home or personal property

Question order adjusted.

26.

BUSINESS DAMAGES

Self Employment is primary income?

□ YES □ NO


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

□ YES □ NO



Disaster Related Expenses (uninsured or under-insured)

Expense Type

Medical

Dental

Funeral

YES__________

NO__________

Insurance Company Name (if insured)__________


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.

27.

Number of claimed dependents__________


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__________


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


Emergency Needs

□ Food, Medication, Durable Medical Equipment, or Gas

□ Shelter

□ Clothing


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.:__________


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

□ E-Mail


Business Damages

Household’s source of income is self-employment?

□ Yes □ No


Own a business or rental property affected by the disaster?

□ Yes □ No


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


No. of Dependents (including yourself)_________

Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


32.

In which language would you like to receive letters?

□ English

□ Spanish


Family’s pre-disaster income before taxes are deducted $__________

Income not available


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


33.

Social Security Administration’s Change of Address Request

When do you want this change to take effect?__________

Make the change effective__________


Electronic Funds Transfer

□ Yes □ No

Bank/Financial Institution Name:__________

Account Type:

□ Checking

□ Savings

□ Routing No._____(9 digits)

Account No.:__________


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


Correspondence language?

□ English

□ Spanish


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.

35.

Comments__________


Traditional postal mail or electronic notification?

□ Postal Mail

□ E-Mail


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.


36.

FEMA Representative__________


Receive text messaging updates?

□ Yes □ No


Mobile Phone No.:__________


Agree to text messaging terms?

□ Yes □ No


Question order adjusted. Question re-worded to match Tele-registration/Internet RI script.

37.

N/A

Comments__________


Question order adjusted.

38.

N/A

FEMA Representative_________


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.


  1. Check Mr. or Ms. to properly address correspondence.


  1. Enter the last name, first name, and middle initial of applicant. Enter JR, SR, III, etc. following the last name if applicable. If the registration is for Business ONLY, enter the business owner’s name or representative (not the business name). If the registration is for Funeral ONLY, enter the name of the person responsible for the funeral expenses.


  1. Enter the language applicant speaks. If the applicant speaks English, leave blank.


  1. Enter applicant's Social Security Number (SSN). If the applicant does not have an SSN but has a dependent child with an SSN, enter the child’s SSN and information in fields 1-6. If the registration is for Business ONLY, enter the responsible party’s SSN, to be used only as an identifier. If the registration is for Funeral ONLY, enter the SSN of the person responsible for the funeral expenses.


  1. Enter applicant’s date of birth.


  1. Enter applicant’s e-mail address, if available.


  1. Accommodation or assistance may include, but is not limited to, sign language interpreter, Braille, large print, accessible electronic format, or materials in a language other than English. FEMA programs may include, but are not limited to, home inspection, town hall meetings, access to a Disaster Recovery Centers, or accessible temporary housing (if eligible). Check Yes or No accordingly. If Yes, check all needs that apply.


  1. The Americans with Disabilities Act (ADA) defines 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 applicant or household member has such a disability, check Yes. If Yes, check all that apply or Prefer Not to Answer.


  1. If the applicant or household member had any disability-related assistive devices or medically required equipment/supplies/support services damaged, destroyed, lost or disrupted because of the disaster, check Yes and check all that apply.


  1. Damaged Dwelling Phone: Beginning with the area code, enter the phone number used at the damaged dwelling at the time of the disaster, even if the number is not currently working. If there was no home phone at the time of the disaster, enter a cell phone or current phone number. Cell Phone: Enter applicant’s cell phone number if applicable.


  1. Current Phone: Enter the current phone number where the applicant can be reached. Alternate Phone: Enter an alternate phone number where FEMA can reach the applicant or leave a message, if applicable. Use the Note field if specific contact information is needed (i.e. family member’s phone number, neighbor, minister, etc.).


  1. Enter the full physical street address exactly as it appears on a utility bill. Do not use any abbreviations, do not enter a “#” symbol and do not enter a PO Box or general delivery address.


  1. If the applicant is named on the deed, or applicant maintains the home, pays no rent and pays taxes (if applicable) or has lifetime occupancy rights while not holding the legal title to the home, check Own. Check Rent if the applicant does not meet any of the ownership criteria, even if the applicant pays no rent.


  1. Check Same as Damaged Address, if applicable. If different, enter the address where the applicant is currently receiving mail. A PO Box or general delivery address may be used.


  1. Check all damage types that apply. Other may include explosion, drought, riot, etc.


  1. Check Yes if the applicant’s home was damaged by the disaster. Check No if no damage to the applicant’s home or if the applicant is applying for Business, Transportation, or Funeral ONLY. Check Unknown if the applicant is unsure of the damage to the home.


  1. Check Yes if the applicant had personal property damage (i.e. appliances, clothing, and/or furniture). Check No if no damage to the applicant’s personal property, or if the applicant is applying for Business, Transportation, or Funeral ONLY. Check Unknown if the applicant is unsure of personal property damage.


  1. Check Yes if the applicant has been without essential utilities for at least 5 days. Check No if the applicant has essential utilities or were without them for less than 5 days.


  1. Check Yes if the applicant has increased financial burden due to new or additional child care costs. Check No if the applicant does not have child care costs or child care costs have not increased.


  1. Check the level of disaster damage to applicant’s home and/or personal property that best applies based on the provided options.


  1. Check the location where the applicant is currently living or staying.


  1. Check the residence type for which the applicant is applying.


  1. Check Yes if the affected home is the applicant’s primary residence (where the applicant lives more than 6 months of the year, listed the address on their Federal Tax Return, or files a homestead exemption at the address). Check No if the affected home is a secondary residence or vacation home, or if the registration is Business, Transportation, or Funeral ONLY.


  1. Check Yes if the residence does not have restricted access, or if the registration is Business, Transportation, or Funeral ONLY. Check No, due to mandatory evacuation if the residence is inaccessible due to mandatory evacuation. Check No, due to damages to roads or bridges in the area if the residence is inaccessible due to damage caused by the disaster.


  1. List all insurance types the applicant held at the time of the disaster for the home and/or personal property, including but not limited to sewer backup, earthquake, and/or flood, and the insurance company name. Check I have no insurance for my home or personal property if there was no insurance coverage for the home or personal property losses.


  1. If the applicant incurred uninsured or underinsured medical, dental, and/or funeral expenses as a direct result of the disaster, check Yes for each applicable expense category. If the applicant had insurance for the expense, list the insurance company name.


  1. Enter all vehicles owned by the applicant or anyone in the household. Year: Enter the year the vehicle was manufactured. Make: Enter the vehicle make. Model: Enter the vehicle model. Damaged: Check Yes or No to indicate if the vehicle was damaged by the disaster (if unknown, check No). Drivable: Check Yes or No to indicate if the vehicle is currently drivable (if unknown, check No). Comprehensive Insurance: Check Yes or No to indicate if the vehicle is covered by comprehensive insurance. Liability Insurance: Check Yes or No to indicate if the vehicle is covered by liability insurance (if unknown, check No). Enter the insurance company name if the vehicle is covered by comprehensive or liability insurance. Registered: Check Yes or No to indicate if the vehicle is registered.


  1. Check each emergency need (essential items for day-to-day existence). Emergency needs do not include stored food.


  1. Enter the information for the applicant and all persons who considered the home to be their primary residence at the time of the disaster, whether or not they are related to the applicant. Include the SSN for only the applicant and co-applicant (if applicable).

  2. Check Yes or No to indicate whether the household’s primary source of income is from self-employment. Check Yes or No to indicate whether the applicant owns or represents a business or rental property affected by the disaster.


  1. Enter the number of dependents, including the applicant and those listed as dependents on their Federal Tax Return.


  1. Enter the pre-disaster household annual gross income (the total household income before any deductions are subtracted, including income from welfare, child support, stocks, interest, and/or annuities. DO NOT include food stamps or HUD Section 8 assistance). If the applicant is "living off savings, family, or friends," enter the approximate amount they receive yearly.


  1. If the applicant is found eligible for FEMA assistance and would like funds directly deposited into their bank account, check Yes. If Yes, enter the name of the applicant's financial institution, their 9-digit routing number (the 9-digit number that appears in the lower left corner of a check), the account type, and the applicant's account number (found at the bottom of a check immediately after the routing number). NOTE: Applicant’s name must be on the account.


  1. Check the language in which the applicant prefers to receive FEMA correspondence.


  1. Check the form of communication through which the applicant prefers to receive FEMA correspondence.


  1. Text messaging is an optional service. Check Yes if the applicant wants to receive text message status alerts in addition to e-mail or postal mail. If Yes, enter the mobile phone number through which the applicant would like to receive text messages. Check Yes or No to indicate if the applicant agrees to the terms of text messaging (FEMA text messages do not replace postal mail or e-mail; FEMA’s text messaging number is 4FEMA [43362]. Please note you may also receive a text message from a FEMA inspector to schedule an appointment for your inspection; Standard text message rates apply.).


  1. Enter any comments.


  1. Enter name of the FEMA representative filling out the form.


Instructions updated to reflect question updates.


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AuthorBentley, Alyssa
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