Form FF-104-FY-21-122 Application / Registration for Disaster Assistance (Engl

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

REC. #

O.M.B. No. 1660-0002
Exp. 8/31/2022
(see reverse side)

APPLICATION/REGISTRATION FOR DISASTER
ASSISTANCE
1. □ Mr.

2. Name of Applicant (last, first, MI)

□ Ms.

3. Language

4. Applicant Social Security No.

DR #

Loss Date

APP. DATE

5. Date of Birth

7. Do you have a disability or language need that requires an accommodation to interact with FEMA staff and/or access FEMA programs?

6. Email

□ Yes □ No

If Yes, what do you need? (select all that apply)

□
□

Sign language interpreter

□
□
□
□
□

Text messages to communicate

□
□

Wheelchair access

□

Language other than English

□
□
□
□
□
□
□
□

CART (Communication Access Realtime Translation) (in person or remote)
Assistive listening device
Braille
Large print
Face-to-face assistance (reader or
writer)

Spanish – Español
Arabic – ‫العربية‬
Haitian Creole – Kreyòl Ayisyen
Russian – Русский
Vietnamese – Tiếng Việt
Samoan – Sāmoa
Mandarin – 中文
Other_________

Other___________

8. 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,

□ Yes □ No

cane, hearing aid, communication device, service animal, personal care attendant, oxygen, dialysis, etc.)
If Yes, select all that apply:

□
□
□
□
□
□
□
□

Mobility
Cognitive/Developmental Disabilities/Mental Health
Hearing/Speech
Vision
Self-Care
Independent Living
Other___________
Prefer Not to Answer

9. 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

10. Damaged Dwelling Phone No. _________________
Cell Phone No. __________________

Adaptive van/vehicle
Walker/cane/crutches
Medication/medical supplies including adult diapers and catheters
Service animal
Personal assistance services/in-home care
Dialysis
Other_____________

11. Current Phone No. _________________
Alternate Phone No. __________________
Note: ________________________

12. Damaged Dwelling Address

13. Do You:

Own

No.

Street

Apt/Lot

City.

State

No.

Street

Apt/Lot

City.

State

Zip

County

Rent

14. Mailing Address

Zip

Same as Damaged Address
15. Damage Type:

□
□

□
□

Flood
Hurricane/Hail/Rain/Wind Driven Rain

16. Home Damage?
Yes

No

□
□

Power Surge/Lightning
Seepage

Tornado/Wind

17. Personal Property Damage (not including vehicles)?
Unknown

Yes

No

□
□

Sewer Backup

18. Utilities Out 5 days or more?

Unknown

Yes

□
□

Earthquake
Fire/Lava Flow/Ash

Ice/Snow
Other___________

19. New or additional child care costs because of disaster?

No

Yes

No

20. 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

21. Current Location?

□
□
□

My Home
Family/Friends
Hotel/Motel

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(05/21)

□
□
□

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

22. Type of Home?

□
□
□

□
□
□

Home-Single/Duplex
Mobile Home
Townhouse

23. Primary Residence?

Yes

□
□
□

Condo
Apartment
Travel Trailer

□
□
□

Assisted Living Facility
Boat
College Dormitory

Correctional Facility
Military Housing
Other________________

24. Currently able to get to your home?

No

Yes

No, due to mandatory evacuation

25. Home/Personal Property Insurance

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

26. Disaster Related Expenses (uninsured or under-insured)

Insurance Type

Insurance Company Name

YES

NO

Insurance Company Name (if insured)

Medical
Dental
Funeral
I have no insurance for my home or personal property
27. Disaster Related Vehicle Damage
Vehicle Information
Year

Make

Damaged?

Model

28. Emergency Needs:

YES

NO

Drivable?
YES

Comprehensive Insurance?

NO

YES

NO

Food, Medication, Durable Medical Equipment or Gas

Liability Insurance?
YES

Insurance Company Name

NO

Shelter

Registered?
YES

NO

Clothing

29. Persons living in your home at time of disaster
Last Name

First Name

MI

Relationship

Social Security Number
(App and Co-App Only)

Age

30. Business Damages
Household’s source of income is self-employment?

Yes

No

Own a business or rental property affected by the disaster?

31. No. of Dependents (including yourself) _______________

Yes

No

32. Family’s pre-disaster income before taxes are deducted $___________________
Income not available

33. Electronic Funds Transfer

Yes

34. Correspondence language?

No

Bank/Financial Institution Name: _____________________________________________________
Account Type:

Checking

Savings

35. Traditional postal mail or electronic notification?

English

Postal Mail

Spanish

E-Mail

Routing No. _______________________ (9 digits)

Account No.: __________________________________________
36. Receive text messaging updates?
Yes

No

Mobile Phone No. ________________________________
Agree to text messaging terms?

Yes

No

37. Comments:

38. FEMA Representative: __________________________________________________________________________________________________________________________________________

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(05/21)

Application/Registration for Disaster Assistance Instructions
1. Check Mr. or Ms. to properly address correspondence.
2. 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.
3. Enter the language applicant speaks. If the applicant speaks English, leave blank.
4. 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.
5. Enter applicant’s date of birth.
6. Enter applicant’s e-mail address, if available.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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.).
12. 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.
13. 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.
14. 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.
15. Check all damage types that apply. Other may include explosion, drought, riot, etc.
16. 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.
17. 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.
18. 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.
19. 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.
20. Check the level of disaster damage to applicant’s home and/or personal property that best applies based on the provided options.
21. Check the location where the applicant is currently living or staying.
22. Check the residence type for which the applicant is applying.
23. 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.
24. 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.
25. 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.
26. 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.
27. 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.
28. Check each emergency need (essential items for day-to-day existence). Emergency needs do not include stored food.
29. 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).
30. 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.
31. Enter the number of dependents, including the applicant and those listed as dependents on their Federal Tax Return.
32. 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.
33. 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.
34. Check the language in which the applicant prefers to receive FEMA correspondence.
35. Check the form of communication through which the applicant prefers to receive FEMA correspondence.
36. 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 email; 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.).
37. Enter any comments.
38. Enter name of the FEMA representative filling out the 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.
FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(05/21)