Notice of Loss and Proof of Loss

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FEMA Form FF-104-F Proof of Loss	Form and Instruction	New	Available
Form FEMA Form FF-104-F Proof of Loss - Individuals and Households	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Notice of Loss	Form and Instruction	New	Available
Form FEMA Form FF-104-F Notice of Loss - Individuals and Households	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Proof of Loss	Form and Instruction	New	Available
Form FEMA Form FF-104-F Proof of Loss - Private Sector	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Notice of Loss	Form and Instruction	New	Available
Form FEMA Form FF-104-F Notice of Loss - Private Sector	Form and Instruction	New	Repair queued
Form FEMA Form FF-204-F Proof of Loss	Form and Instruction	New	Available
Form FEMA Form FF-204-F Proof of Loss - State, Local, and Tribal Governments	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Notice of Loss	Form and Instruction	New	Available
Form FEMA Form FF-104-F Notice of Loss - State, Local, and Tribal Governments	Form and Instruction	New	Repair queued
FEMA_IFR Hermits Peak.pdf	Supplementary Document	Uploaded 2022-11-14	Available
Hermits Peak Public Inspection IFR.pdf	Supplementary Document	Uploaded 2022-11-10	Repair queued
Emergency Justification Memo_Hermits Peak Notice of Loss_ final.pdf	Supplementary Document	Uploaded 2022-11-08	Available
Emergency Justification Memo_Hermits Peak Notice of Loss_ final.pdf	Supplementary Document	Uploaded 2022-11-08	Repair queued
Supporting Statement Hermits Peak Notice of Loss and Proof of Loss 20221024.docx	Supporting Statement A	Uploaded 2022-11-08	Available
Supporting Statement Hermits Peak Notice of Loss and Proof of Loss 20221024.docx	Supporting Statement A	Uploaded 2022-11-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
256772	Proof of Loss - Individuals and Households	Form and Instruction	New	Proof of Loss
256772	Proof of Loss - Individuals and Households	Form and Instruction	New
256771	Notice of Loss - Individuals and Households	Form and Instruction	New	Notice of Loss
256771	Notice of Loss - Individuals and Households	Form and Instruction	New
256770	Proof of Loss - Private Sector	Form and Instruction	New	Proof of Loss
256770	Proof of Loss - Private Sector	Form and Instruction	New
256769	Notice of Loss - Private Sector	Form and Instruction	New	Notice of Loss
256769	Notice of Loss - Private Sector	Form and Instruction	New
256768	Proof of Loss - State, Local, and Tribal Governments	Form and Instruction	New	Proof of Loss
256768	Proof of Loss - State, Local, and Tribal Governments	Form and Instruction	New
256767	Notice of Loss - State, Local, and Tribal Governments	Form and Instruction	New	Notice of Loss
256767	Notice of Loss - State, Local, and Tribal Governments	Form and Instruction	New

ICR Details

OMB Control No: 1660-0155	ICR Reference No: 202211-1660-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DHS/FEMA	Agency Tracking No: Emergency - Hermit's Peak (1660-NW162)
Title: Notice of Loss and Proof of Loss
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 11/14/2022
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/14/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/10/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2023	6 Months From Approved
Responses	57,450	0	0
Time Burden (Hours)	667,857	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Hermit’s Peak/Calf Canyon Fire Assistance Act is intended to provide persons who suffered injuries as a result of Hermit’s Peak/Calf Canyon Fires with a simple, expedited process to seek compensation from the United States. To obtain benefits under this legislation, an Injured Person must submit all Hermit’s Peak/Calf Canyon Fires related claims against the United States to the Federal Emergency Management Agency (FEMA). An Injured Person who elects to proceed under the Act is barred from bringing a claim under the Federal Tort Claims Act or filing a civil action against the United States for damages resulting from the Hermit’s Peak/Calf Canyon Fires.

Emergency Justfication: Congress tasked the Federal Emergency Management Agency (FEMA) with providing expeditious consideration and settlement of claims for injuries as a result of the Hermit’s Peak/Calf Canyon Fire. In doing so, Congress set strict deadlines around the claims process. First, FEMA is required to publish interim regulations establishing the process by November 14, 2022. Once the process is established in regulation, Claimants will have two years from the date the regulation is published to submit their Notice of Loss to FEMA. The Notice of Loss provides confirmation that the Claimant has elected to use the process under the Act to seek compensation for injuries resulting from the Hermit’s Peak/Calf Canyon Fires and formally begins the claims process. Without immediate access to the Notice of Loss, Claimants will not have the full period of time available under the statute to submit their claim. Following the normal clearance procedures for approval, this information collection will delay FEMA’s ability to expeditiously consider and settle claims arising from injuries as a result of the Hermit’s Peak/Calf Canyon Fire. The victims of this Fire deserve compensation for their injuries and Congress has demanded immediate action to compensate them.

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Authorizing Statute(s): PL: Pub.L. 117 - 180 136-2114 Name of Law: Hemits Peak/Calf Canyon Fire Assistance Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1660-AB14	Final or interim final rulemaking	87 FR 68085	11/14/2022

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Notice of Loss - Individuals and Households	FEMA Form FF-104-FY-22-230	Notice of Loss
Notice of Loss - Private Sector	FEMA Form FF-104-FY-22-231	Notice of Loss
Notice of Loss - State, Local, and Tribal Governments	FEMA Form FF-104-FY-22-230	Notice of Loss
Proof of Loss - Individuals and Households	FEMA Form FF-104-FY-22-231	Proof of Loss
Proof of Loss - Private Sector	FEMA Form FF-104-FY-22-231	Proof of Loss
Proof of Loss - State, Local, and Tribal Governments	FEMA Form FF-204-FY-22-231	Proof of Loss

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	57,450	0	0	57,450	0	0
Annual Time Burden (Hours)	667,857	0	0	667,857	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $112,855,026

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/10/2022

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