Form FEMA Form 009-0-95 FEMA Form 009-0-95 Request for Advance Disaster Assistance

This form is part of the Advance Request letter. However, OCC states this form should be an OBM form.

Request for Advance Disaster Assistance

Disaster Number: {DSTR_NR}

FEMA Application Number: {RGSN_ID}

{APPL_NM}

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; and,

• 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) Date

_________________________________________

FEMA Co-applicant Name (Printed)

_________________________________________

Signature