FEMA Form FF-104-F Application for Continued Temporary Housing Assistance (

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB No. 1660-0061
Expires January 31, 2024

INDIVIDUALS AND HOUSEHOLDS PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
Instructions for Completing Your Application for Continued Temporary Housing Assistance
Please read these instructions prior to filling out your "Application for Continued Temporary Housing Assistance".
STEP ONE: Fill out the form. NOTE: After your initial "Application for Continued Temporary Housing Assistance" is approved, the "Pre-Disaster or
Prior Reported" column on the form will be filled-in for you, using the information provided by you in your previously approved request.
Items 1-6
Items 1 through 6 will be filled-in for you, using the information provided by you at registration. If the information supplied on the form is correct, you
may move on to Item 7: "Housing Costs." However, if the information is incorrect, please check the box that is incorrect and provide the updated
information.
Current Mailing Address is the address you want FEMA to send you disaster assistance information, such as letters regarding your eligibility for
continued temporary housing assistance.
Current Phone is the phone number that FEMA can use to contact you about your application for continued temporary housing assistance and other
disaster assistance.
Item 7
You will need to supply the dollar amount of both pre-disaster and current expenses that are applicable to your household.
Next to the appropriate "Expense" enter the dollar amount of your bill or payment.
You must submit a copy of each document to prove the dollar amount included as a "Housing Cost." This would include documents such as
your mortgage statement, rent receipts and utility bills. Shade in the circle next to the "Expense" indicating that you have attached the document to
your application. You must submit documentation that can be verified; otherwise the amount will not be accepted.
Under "Payment Cycle", shade in the circle indicating how you are billed for the housing expense.

Expense

Pre Disaster
or
Prior Reported

Mortgage

$1495.00

7. Housing Costs (See Instructions for Definitions of Expenses)
Payment Cycle (How You Are Billed)
Shade if
Current
Document is
Monthly Quarterly Bi-Annual
Annual
Attached
(1)
(4)
(6)
(12)

Other

$1495.00

Definitions for certain expenses have been provided below.
Home Insurance means typical homeowners, renters, flood, or earthquake insurance policy or any other type of insurance policy or rider for the
dwelling.
Housing Cost means the rent and/or mortgage payments (including principal, interest, and real estate taxes), real property insurance, and utility costs
(not to include cable television, internet, and telephone service).
Housing Unit means a house, apartment, a manufactured home, recreational vehicle, or other readily fabricated dwelling. A room or group of rooms
in an occupied dwelling may qualify as a housing unit if the room(s) in which the applicant and household live are separate from any other persons in
the dwelling/building, and are generally available to be rented by the public.
Item 8
In addition to providing a copy of your written and signed lease, you will have to provide the name and phone number of the landlord. The lease
must be signed by the applicant or co-applicant and the landlord.
QUESTIONS OR NEED ASSISTANCE?
If you have any questions about completing this document, you should call the FEMA Disaster Helpline at 1-800-621-FEMA (3362) (hearing/speech
impaired only: 1-800-462-7585) as soon as possible.

FEMA Form FF-104-FY-21-115 (formerly 010-0-12)
(3/21)

Page 1 of 4

Instructions for Completing Your Application for Continued Temporary Housing Assistance
Item 9
You will need to supply the pre-disaster and current income information for each individual -18 years of age or older - who is currently living with you
at your temporary residence.
You must submit documentation to verify each dollar amount you supplied on the form, and you will also need to provide how often each
individual is paid by his or her employer. Shade in the circle indicating you have attached a document to your application.
Shade in the circle indicating how often each individual is paid by his or her employer. If an individual has more than one job, please list them
separately for each job. If the pay cycle is not listed, please shade in the circle for "Other''.
See example below:
9. Income Information for All Individuals 18 years of Age and Older Living in Current Temporary Residence
Payment Cycle (How You Are Billed)
Gross Income
Shade if
Name
Document is
Pre Disaster
Twice
Current
Weekly
Monthly Quarterly
Attached
or Prior Reported
Monthly
Maria Quin

$1495.00

Other

$1495.00

Income means 1) Wages and salaries, overtime pay, commissions, fees, tips and bonuses and other compensation for personal services; 2) Interest,
dividends and other net income of any kind from real or personal property; 3) Full amount of periodic amounts received from Social Security,
annuities, insurance policies, retirement funds, pensions, disability or death benefits and other similar types of periodic receipts, including lump-sum
amount or prospective monthly amounts for the delayed start of a periodic amount; 4) Payments in lieu of earnings, such as unemployment and
disability compensation, worker's compensation and severance pay; and 5) Welfare assistance.
Item 10
You will need to check whichever box is applicable to your pre-disaster housing situation and your permanent housing plan. If you plan on moving in
with your friends/family, you must supply your projected move in date.
Item 11
Please read this section thoroughly. NOTE: All of the bullet points may not be applicable to your household situation. However, in order to be eligible
for Continued Temporary Housing Assistance, the information contained in those bullet points that are applicable to your household situation must be
true and accurate. If the information is not true to your situation, then you are not eligible for Continued Temporary Housing Assistance and will not
need to fill out this form.
Item 12
Once you have reviewed the form for accuracy, you will need to read the declarations statement and sign and date the form. When signing the form,
please use blue or black ink.
STEP TWO: Attach supporting documentation to application (e.g. pay stubs, mortgage statements, lease, utility bills, rent receipts, etc.)
STEP THREE: Submit the application and your supporting documents to FEMA.
QUESTIONS OR NEED ASSISTANCE?
If you have any questions about completing this document, you should call the FEMA Disaster Helpline at 1-800-621-FEMA (3362) (hearing/speech
impaired only: 1-800-462-7585) as soon as possible.

FEMA Form FF-104-FY-21-115 (formerly 010-0-12)
(3/21)

Page 2 of 4

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1660-0061
Expires January 31, 2024

Federal Emergency Management Agency

INDIVIDUALS AND HOUSEHOLDS PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1 hour 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 0MB 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 Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0061). NOTE: Do not send your completed form
to this address.

PRIVACY NOTICE
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 93-288, as amended, 42 U.S.C. §§ 5121 -5207; The Homeland Security
Act of 2002, P.L. No. 107-296, as amended, 6 U.S.C. §§ 311-321j; Reorganization Plan No. 3 of 1978; 4 U. S.C. §§ 2904 and 2906; 4 C.F.R. § 206.2(a)(27); the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193); and Exec. Order No. 13411. Disaster Mitigation Act of 2000 (DMA 2000), P.L. 106-390,
amended the Stafford Act. Post-Katrina Emergency Management Reform Act of 2006, Pub. L. No. 109-295. Sandy Recovery Improvement Act of 2013 (SRIA), Pub. L. No.
113-2.
PRINCIPAL PURPOSE($): FEMA collects and maintains your information in order to determine eligibility for and administer financial assistance under a Presidentiallydeclared disaster. Additionally, FEMA may review your information for quality assurance purposes to assess FEMA's disaster assistance customer service.
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 detailed in 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.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent you from receiving
FEMA benefits.

1. APPLICANT NAME

2. DISASTER #

3. CURRENT MAILING ADDRESS

4. REGISTRATION #

5. CURRENT PHONE

6. ALTERNATE PHONE

CHECK HERE IF CURRENT MAILING ADDRESS IS DIFFERENT
AND PROVIDE NEW ADDRESS BELOW:

CHECK HERE IF CURRENT PHONE IS DIFFERENT AND
PROVIDE NEW NUMBER BELOW:

IMPORTANT NOTICE: Requirements for Applying for Continued Temporary Assistance. In order for FEMA to effectively evaluate a
continuing need for temporary housing, it is necessary that we have you submit documentation on your pre-disaster and current housing
costs, pre-disaster and current income and verifiable documentation of income, permanent housing plan, current lease, rent receipts/
cancelled checks, and mortgage payment information.
7. Housing Costs (See Instructions for Definitions)
Expense

Pre Disaster or
Prior Reported

Current

Shade if
Document is
Attached

Payment Cycle (How You Are Billed)
Monthly
(1)

Quarterly
(4)

Bi-Annual
(6)

Annual
(12)

Other

Mortgage
Real Estate Taxes (If paid separately
from Mortgage)
Home Insurance (If paid separately
from Mortgage)
Rent for Housing Unit
Water
Electric
Gas
Oil
Propane
Sewer
Trash
Other:

FEMA Form FF-104-FY-21-115 (formerly 010-0-12)
(3/21)

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8. Current Landlord Contact Information
NAME

PHONE NUMBER

9. Income Information for All Individuals 18 years of Age and Older Living in Current Temporary Residence
Gross Income
Name

Pre Disaster or
Prior Reported

Current

Shade if
Document is
Attached

Pay Cycle
Weekly

Twice
Monthly

Monthly

Quarterly

Other

10. Permanent Housing Plan
I am a pre-disaster RENTER and my permanent housing plan is to:
Locate a rental resource within my family's financial ability
Move in with friends/family

Projected move in date:

I am a pre-disaster HOMEOWNER and my permanent housing plan is to:
Repair or rebuild my damaged home
Purchase a home using my disaster related assistance, including any insurance
Become a renter and locate a rental resource within my family's financial ability
Move in with friends/family

Projected move in date:

11. Conditions for Receiving Continued Temporary Housing Assistance
My household understands that in order to be eligible for Continued Temporary Housing Assistance, the following information must be true and
accurate:
• My household has a continuous need for Temporary Housing Assistance because our housing needs are not being met by another source,
i.e., my household is not receiving housing assistance from another public agency such as the U.S. Department of Housing and Urban
Development, U.S.Department of Veterans Affairs, a local housing agency, or any other agency or organization providing housing.
• My household does not own a secondary home or a vacation home within a reasonable commuting distance of our pre-disaster home.
• My household cannot live in and/or access our pre-disaster primary home due to the disaster.
• My household has looked and is continuing to look for but has not yet found an alternative, adequate home that is within reasonable
commuting distance of work and/or school and is within our financial ability.
• My household has been and is currently working to repair our pre-disaster primary home (Applicable only for those who have chosen to rebuild
theirpre-disaster primary home).
If any of the above statements are not true to your situation, then you are not eligible for Continued Temporary Housing Assistance and
donot need to submit this form.
12. CERTIFICATION
I understand that if I intentionally make false statements, submit fraudulent information, or conceal any information in an attempt to obtain
additional disaster assistance, it is a violation of federal and state laws, which carries criminal and civil penalties, including fines,
imprisonment, or both.
I hereby declare under penalty of perjury that the foregoing is true and correct.

Head of Household (Applicant/Co-Applicant) Signature

FEMA Form FF-104-FY-21-115 (formerly 010-0-12)
(3/21)

Date

Date Form Mailed to Applicant

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