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}
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.
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 #: ______________________
I understand before this request for advancement is approved, FEMA will inspect my home for the purpose of recording the disaster-caused damage.
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
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
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Aponte Olmo, Rafael |
File Modified | 0000-00-00 |
File Created | 2022-02-15 |