Form FEMA Form FF-104-F FEMA Form FF-104-F Proof of Loss

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-NW162
Expiration Date: XX/XX/20XX

Hermit's Peak/Calf Canyon Fire Assistance Act

PROOF OF LOSS - HERMIT'S PEAK/CALF CANYON FIRE
CLAIMANT CONTACT INFORMATION
Name:
Street:
City, State, Zip:
Day Phone:

Evening Phone:

E-mail Address:

Fax No.:
What is the best time to reach you?

Claim Number:
For verification purposes, please provide one or more of the following:
Social Security Number and/or Tax Identification Number
Business Identification Number
Other form of identification (Driver's license, Student ID, etc.)

DRAFT

Note that compensation under the Hermit’s Peak/Calf Canyon Fire Assistance Act is available to all injured persons, regardless of
the citizenship or alien status of the individual.

TYPE OF CLAIM

What type of claim does this Proof of Loss cover? (Check only one option)
Individual or Household
Business

Indian Tribe

Not-for-Profit

Government

Other:

This Proof of Loss relates to the Notice of Loss filed by the Claimant on

and is submitted pursuant to the Hermit's

Peak/Calf Canyon Fire Assistance Act for injuries resulting from the Hermit’s Peak/Calf Canyon Fire.

AMOUNTS CLAIMED
The following are the amounts claimed, by category, by the Claimant:
INDIVIDUAL OR HOUSEHOLD
Personal injury
General Damages
Medical Expenses
Lost Wages/Personal Income (Injury-related)
Real property

$
$
$

Address:

Repair
Replacement
Decreased value
Reforestation and/or revegetation
Debris removal and other clean-up costs
Heightened risk reduction

$
$
$
$
$
$

Personal property

$

Lost wages/Personal income (not injury-related)

$

FEMA Form FF-104-FY-22-231 (10/22)

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INDIVIDUAL OR HOUSEHOLD (Continued)
Increased mortgage interest costs

$

Flood insurance premiums

$

Insurance deductible

$

Temporary living/Relocation expense

$

Subsistence Resources

$

Other (brief description)
BUSINESS OR NON-PROFIT ORGANIZATION
Real property

Address:

Repair
Replacement
Decreased value
Reforestation and/or revegetation
Debris removal and other clean-up costs
Heightened risk reduction

$
$
$
$
$
$

Personal property/Tangible assets/Inventory

$

Business interruption

$

Overhead costs

DRAFT
$

Emergency staffing expenses

$

Employee wages for unperformed work

$

Increased mortgage interest costs

$

Flood insurance premiums

$

Insurance deductible

$

Temporary rental/relocation expense

$

Other

$

GOVERNMENT (STATE, TRIBAL OR LOCAL)
Real property

Address:

Repair
Replacement
Decreased value
Reforestation and/or revegetation
Debris removal and other clean-up costs
Heightened risk reduction

$
$
$
$
$
$

Personal property/Tangible assets/Inventory

$

Firefighting costs and Emergency response

$

Emergency staffing expenses

$

Administrative expenses

$

Increased mortgage interest costs

$

Temporary rental/Relocation expense

$

Tribal subsistence resources

$

Other

$

Total Amount Claimed

$

FEMA Form FF-104-FY-22-231 (10/22)

0.00
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A statement describing the nature and extent of each injury for which compensation is sought must be attached to this Proof of Loss.
Please coordinate with your Claims Reviewer if you have any questions about the information to include with this Proof of Loss.
Write your name and claim number on all documents submitted with this form. Please keep all original documents and retain a copy
of this Proof of Loss form for your records.

DRAFT

YOU MUST SIGN THE CERTIFICATION ON PAGE 4 BEFORE SUBMITTING THIS PROOF OF LOSS
FEMA Form FF-104-FY-22-231 (10/22)

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CERTIFICATION
This Proof of Loss consists of this form and the attached documents supporting the claim(s). The undersigned Claimant (or legal
representative of the Claimant) declares under penalty of perjury under the laws of the United States that all of the information on
this form is true and correct. The undersigned Claimant (or legal representative of the Claimant) further certifies under penalty of
perjury that no amount claimed in this Proof of Loss has been paid or will be paid by insurance, other assistance programs, or any
other source.
Individual and Household Claimants Sign Below:
1. Name of Claimant:

Claimant Signature

Date

2. Name of Claimant:

Claimant Signature

Date

Other Claimants and Legal Representatives of Individual Claimants Sign Below:
Name of Claimant:

DRAFT

Signature of duly authorized legal representative of Claimant

Date

Title of legal representative or Relationship to Claimant

FEMA Form FF-104-FY-22-231 (10/22)

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PRIVACY ACT NOTICE
This Notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a(e)(3), and concerns the information requested in the Notice of Loss form to
which this Notice is attached. The authority for the collection of this information is Hermit’s Peak/Calf Canyon Fire Assistance Act, Public Law
117-180. The information you provide will be used to verify your identity, to verify your eligibility, and to verify any previous compensation made in
connection with the Hermit’s Peak/Calf Canyon Fire. Some or all of the information you provide may be released to federal, state, and local
government agencies or private organizations for the purpose of confirming your identity, your eligibility and any previous compensation or payments
made in connection with the Hermit’s Peak/Calf Canyon Fire. The information may also be released when otherwise authorized by statute or
regulation. Disclosure of the information by you is required in order for you to make a claim under the Act. It will not be possible to process your claim
without the information.
Routine Uses: The Privacy Act permits us to disclose information about individuals without their consent for a routine use, i.e., when the information
will be used for a purpose that is compatible with the purpose for which we collected the information. The routine uses of this system are:
a) Disclosure may be made to agency contractors who have been engaged to assist the agency in the performance of a contract service related
to this system of records and who need to have access to the records in order to perform the activity. Recipients shall be required to comply
with the requirements of the Privacy Act of 1974, as amended, 5 U.S.C.552a.
b) Disclosure may be made to a member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office
made at the written request of the constituent about whom the record is maintained.
c) Disclosure may be made to other Federal agencies that FEMA has determined provided Hermit’s Peak/Calf Canyon fire-related assistance to
claimant in order to ensure that benefits are not duplicated.
d) Disclosure of information submitted by an individual claimant may be made to an insurance company or other third party which has submitted
a subrogation claim relating to such claimant when it is necessary in FEMA’s opinion to ensure that benefits are not duplicated and to
efficiently coordinate the processing of claims brought by individuals and subrogees.

DRAFT

e) When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal or
regulatory in nature, and whether arising by general statuteor particular program statute, or by regulation, rule, or order issued pursuant
thereto, disclosure may be made to the appropriate agency, whether Federal, foreign, State, local, or tribal or other public authority
responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation,
or order issued pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative or prosecutive
responsibility of the receiving entity.
f) Disclosure may be made to the National Archives and Records Administration for the purpose of conducting records management studies
under the authority of 44 U.S.C. 2904 and 2906.
Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply the requested information or to execute the form may render your
claim “invalid.”

NOTICE OF PAPERWORK REPORTING BURDEN DISCLOSURE
Public reporting burden for this form is estimated to average 45 minutes. Burden means the time, effort, and financial resources expended by
persons to generate, maintain, retain, disclose, or to provide information. You may send comments regarding the burden estimate or any aspects of
the form, including suggestions for reducing the burden to: Information Collection Management, Federal Emergency Management Agency, 500 C
Street SW, Washington, DC 20472. Please do not send your completed Notice of Loss to this address. You are not required to respond to this
collection of information unless a valid OMB control number appears in the upper right corner of this form.

FEMA Form FF-104-FY-22-231 (10/22)

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