Form FEMA Form FF-104-F FEMA Form FF-104-F Application for Loan Cancellation

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control Number: 1660-0083
Expiration: 8/31/2023

APPLICATION FOR LOAN CANCELLATION

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1 hour per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing,and submitting the form.
You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, and Paperwork Reduction Project
(1660-0082). Note: Do not send your completed form to this address.
FOR FEDERAL GOVERNMENT USE ONLY

1. Entity name, authorized representative, mailing address, phone, contact e-mail

Loan Number
-

CDL
Disaster Declaration Date

3. Date Promissory Note Executed

2. Total Approved Loan Amount

4. Term of Loan

5. Interest Rate

SUMMARY OF CANCELLATION INFORMATION
Fiscal Year
Fiscal Year of
Preceding Disaster
Disaster

Disaster FY+1 Disaster FY+2

Disaster FY+3

TOTAL
Post Disaster

6. Fiscal Year End Date
7. Total Operating Revenues
8. Operating Expenses
(less UDRE if used)
9. Un-reimbursed Disaster Related
Expenses
10. Total Operating Expenses [8 + 9]
11. Net Operating Surplus or (Deficit)
[7 - 10]
12. Total CDL Funds Drawn
13. Cancellation Request (Total of line 11 deficit, up to amount of CDL, line 12)
Based on the information contained in the Application for the Community Disaster Loan, the Promissory Note executed
20

and the information furnished above apply for loan cancellation in the amount of $

in connection with the

loan already made as a result of the loss caused by a major disaster declaration on
Date

Signature of Applicant
FORWARDED
Name and Title of Approval Official (Governor's Authorized Representative)

RECOMMENDATION:

FEMA FORM 009-0-15 (06/16)

DISAPPROVAL
Signature

Date

Plus Related Interest is Hereby

$
APPROVED

Name and Title of Approval Official

Date

FOR FEMA USE ONLY
APPROVAL

Name and Title of Approval Official (Regional Director)

Principal cancellation in the amount of

Signature

DISAPPROVED
Signature

Date

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