Form FEMA Form FF-104-F FEMA Form FF-104-F Request for Advance Disaster Assistance

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-0061
Expires January 31, 2024

REQUEST FOR ADVANCE DISASTER ASSISTANCE
Disaster Number:
FEMA Application Number:

I, the undersigned, hereby certify that I am the insured occupant of the following damaged property:
I am requesting advanced Rental Assistance for
my insured expenses caused by the disaster. I understand this request does not guarantee I will receive an advance from FEMA.
1.

I authorize FEMA to verify with my insurance company that I have filed a claim for the address listed above. I authorize my
insurance company to release to FEMA all verifying information related to my insurance claim.
Insurance Company Name:
Insurance Company Phone #:
Date Claim was Filed:

Claim #:

2.

I understand before this request for advancement is approved, FEMA will inspect my home for the purpose of recording the
disaster-caused damage.

3.

When I receive my insurance proceeds, I agree to immediately reimburse FEMA for the full amount of this advance. I will
either mail a personal check or money order to:
MAIL TO:
FEMA
P.O. Box 6200-16
Portland, OR 97228-6200

4.

I understand if I fail to repay this advance, FEMA will initiate debt collection actions, which may include:
•

Adding interest and penalties to the amount owed;

•

Reporting your debt to national consumer credit reporting agencies;

•

Referring the debt to the U.S. Department of the Treasury, where payment of your debt may be taken from other
federal payments due to you, such as a tax refund. Additional fees may also be charged and added to the debt
amount.

This Request for Advancement is submitted pursuant to 28 U.S.C § 1746 under penalty of perjury. I understand that it is my choice to
request this advancement and to sign this Request for Advancement.

FEMA Applicant Name (Printed)

FEMA Co-Applicant Name (Printed)

Signature

FEMA Form FF-104-FY-21-116 (formerly 009-0-95)
(3/21)

Date

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