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 Request to Supplement Claim (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Request to Supplement Claim	Form and Instruction	New	Available
Form FEMA Form FF-104-F Request to Supplement Claim - Individuals and Households	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Request to Supplement Claim (Spanish)	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Request to Supplement Claim	Form and Instruction	New	Available
Form FEMA Form FF-104-F Request to Supplement Claim - Private Sector	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Request to Supplement Claim (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Requeset to Supplement Claim	Form and Instruction	New	Available
Form FEMA Form FF-104-F Request to Supplement Claim - State, Local and Tribal Governments	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Partial Payment Release and Certification Form (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Partial Payment Release and Certification Form	Form and Instruction	New	Available
Form FEMA Form FF-104-F Partial Payment Release and Certification Form - Individuals and Households	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Partial Payment Release and Certification Form (Entity) (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Partial Payment Release and Certification Form (Entity)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Partial Payment Release and Certification Form (Entity) - Private Sector	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Partial Payment Release and Certification Form (Entity) (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Partial Payment Release and Certification Form (Entity)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Partial Payment Release and Certification Form (Entity) - State, Local and Tribal Governments	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Banking Information (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Banking Information	Form and Instruction	New	Available
Form FEMA Form FF-104-F Banking Information - Individuals and Households	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Banking Information (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Banking Information	Form and Instruction	New	Available
Form FEMA Form FF-104-F Banking Information - Private Sector	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Banking Information (Spanish)	Form and Instruction	New	Available
Form FEMA Form FF-104-F Banking Information	Form and Instruction	New	Available
Form FEMA Form FF-104-F Banking Information - State, Local & Tribal Governement	Form and Instruction	New	Repair queued
Form FEMA Form FF-104-F Proof of Loss (Spanish)	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Proof of Loss	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Proof of Loss - Individuals and Households	Form and Instruction	Modified	Repair queued
Form FEMA Form FF-104-F Notice of Loss (Spanish)	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Notice of Loss	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Notice of Loss - Individuals and Households	Form and Instruction	Modified	Repair queued
Form FEMA Form FF-104-F Proof of Loss (Spanish)	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Proof of Loss	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Proof of Loss - Private Sector	Form and Instruction	Modified	Repair queued
Form FEMA Form FF-104-F Notice of Loss (Spanish)	Form and Instruction	Modified	Repair queued
Form FEMA Form FF-104-F Notice of Loss	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Notice of Loss - Private Sector	Form and Instruction	Modified	Repair queued
Form FEMA Form FF-204-F Proof of Loss (Spanish)	Form and Instruction	Modified	Available
Form FEMA Form FF-204-F Proof of Loss	Form and Instruction	Modified	Available
Form FEMA Form FF-204-F Proof of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified	Repair queued
Form FEMA Form FF-104-F Notice of Loss (Spanish)	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Notice of Loss	Form and Instruction	Modified	Available
Form FEMA Form FF-104-F Notice of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified	Repair queued
FEMA_IFR Hermits Peak.pdf	Supplementary Document	Uploaded 2022-11-14	Available
FEMA_IFR Hermits Peak.pdf	Supplementary Document	Uploaded 2022-11-14	Repair queued
1660-0155_Emergency Justification Memo_Hermits Peak Notice of Loss_ 02.8.2023.pdf	Supplementary Document	Uploaded 2023-02-14	Available
1660-0155_Emergency Justification Memo_Hermits Peak Notice of Loss_ 02.8.2023.pdf	Supplementary Document	Uploaded 2023-02-14	Repair queued
1660-0155 - Supporting Statement A - 2023 02 10 clean.docx	Supporting Statement A	Uploaded 2023-02-10	Available
1660-0155 - Supporting Statement A - 2023 02 10 clean.docx	Supporting Statement A	Uploaded 2023-02-10	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
258474	Request to Supplement Claim - Individuals and Households	Form and Instruction	New	Request to Supplement Claim (Spanish)
258474	Request to Supplement Claim - Individuals and Households	Form and Instruction	New	Request to Supplement Claim
258474	Request to Supplement Claim - Individuals and Households	Form and Instruction	New
258473	Request to Supplement Claim - Private Sector	Form and Instruction	New	Request to Supplement Claim (Spanish)
258473	Request to Supplement Claim - Private Sector	Form and Instruction	New	Request to Supplement Claim
258473	Request to Supplement Claim - Private Sector	Form and Instruction	New
258472	Request to Supplement Claim - State, Local and Tribal Governments	Form and Instruction	New	Request to Supplement Claim (Spanish)
258472	Request to Supplement Claim - State, Local and Tribal Governments	Form and Instruction	New	Requeset to Supplement Claim
258472	Request to Supplement Claim - State, Local and Tribal Governments	Form and Instruction	New
258470	Partial Payment Release and Certification Form - Individuals and Households	Form and Instruction	New	Partial Payment Release and Certification Form (Spanish)
258470	Partial Payment Release and Certification Form - Individuals and Households	Form and Instruction	New	Partial Payment Release and Certification Form
258470	Partial Payment Release and Certification Form - Individuals and Households	Form and Instruction	New
258469	Partial Payment Release and Certification Form (Entity) - Private Sector	Form and Instruction	New	Partial Payment Release and Certification Form (Entity) (Spanish)
258469	Partial Payment Release and Certification Form (Entity) - Private Sector	Form and Instruction	New	Partial Payment Release and Certification Form (Entity)
258469	Partial Payment Release and Certification Form (Entity) - Private Sector	Form and Instruction	New
258466	Partial Payment Release and Certification Form (Entity) - State, Local and Tribal Governments	Form and Instruction	New	Partial Payment Release and Certification Form (Entity) (Spanish)
258466	Partial Payment Release and Certification Form (Entity) - State, Local and Tribal Governments	Form and Instruction	New	Partial Payment Release and Certification Form (Entity)
258466	Partial Payment Release and Certification Form (Entity) - State, Local and Tribal Governments	Form and Instruction	New
258464	Banking Information - Individuals and Households	Form and Instruction	New	Banking Information (Spanish)
258464	Banking Information - Individuals and Households	Form and Instruction	New	Banking Information
258464	Banking Information - Individuals and Households	Form and Instruction	New
258463	Banking Information - Private Sector	Form and Instruction	New	Banking Information (Spanish)
258463	Banking Information - Private Sector	Form and Instruction	New	Banking Information
258463	Banking Information - Private Sector	Form and Instruction	New
258462	Banking Information - State, Local & Tribal Governement	Form and Instruction	New	Banking Information (Spanish)
258462	Banking Information - State, Local & Tribal Governement	Form and Instruction	New	Banking Information
258462	Banking Information - State, Local & Tribal Governement	Form and Instruction	New
256772	Proof of Loss - Individuals and Households	Form and Instruction	Modified	Proof of Loss (Spanish)
256772	Proof of Loss - Individuals and Households	Form and Instruction	Modified	Proof of Loss
256772	Proof of Loss - Individuals and Households	Form and Instruction	Modified
256771	Notice of Loss - Individuals and Households	Form and Instruction	Modified	Notice of Loss (Spanish)
256771	Notice of Loss - Individuals and Households	Form and Instruction	Modified	Notice of Loss
256771	Notice of Loss - Individuals and Households	Form and Instruction	Modified
256770	Proof of Loss - Private Sector	Form and Instruction	Modified	Proof of Loss (Spanish)
256770	Proof of Loss - Private Sector	Form and Instruction	Modified	Proof of Loss
256770	Proof of Loss - Private Sector	Form and Instruction	Modified
256769	Notice of Loss - Private Sector	Form and Instruction	Modified	Notice of Loss (Spanish)
256769	Notice of Loss - Private Sector	Form and Instruction	Modified	Notice of Loss
256769	Notice of Loss - Private Sector	Form and Instruction	Modified
256768	Proof of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified	Proof of Loss (Spanish)
256768	Proof of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified	Proof of Loss
256768	Proof of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified
256767	Notice of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified	Notice of Loss (Spanish)
256767	Notice of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified	Notice of Loss
256767	Notice of Loss - State, Local, and Tribal Governments	Form and Instruction	Modified

ICR Details

OMB Control No: 1660-0155	ICR Reference No: 202302-1660-001
Status: Historical Active	Previous ICR Reference No: 202211-1660-001
Agency/Subagency: DHS/FEMA	Agency Tracking No: Second Emergency (Hermit's Peak)
Title: Notice of Loss and Proof of Loss
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 02/15/2023
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/16/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/15/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2023	6 Months From Approved	05/31/2023
Responses	143,625	0	57,450
Time Burden (Hours)	689,401	0	667,857
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: This information is necessary to support the Act implemented by the Hermit’s Peak/Calf Canyon Fire Assistance regulation (44 CFR part 296) which was added by FEMA’s November 10, 2022, Hermit’s Peak/Calf Canyon Fire Assistance Interim Final Rule (RIN 1660-AB14). The purpose of this authority is to ensure the expeditious consideration and settlement of claims to compensate victims of the Hermit’s Peak/Calf Canyon Fires. The Hermit’s Peak Fire began on April 6, 2022, after a prescribed burn exceeded the containment capabilities of the U.S. Forest Service and was declared a wildfire. On April 19, the Calf Canyon Fire began burning on Federal land and was later identified as the result of a pile burn in January 2022 that remained dormant under the surface before reemerging. The Hermit’s Peak and Calf Canyon Fires merged on April 27, 2022. By May 2, 2022, the fire had grown, causing evacuations in multiple villages and communities. On May 4, 2022, President Biden issued a major disaster declaration for the counties of Colfax, Mora, and San Miguel, New Mexico. The U.S. Forest Service has assumed responsibility for the Hermit’s Peak/Calf Canyon Fire, which was not 100 percent contained until August 21, 2022. On September 30, 2022, Congress passed the Act authorizing FEMA to establish a claims process for victims of the Hermit’s Peak/Calf Canyon Fire. Congress tasked 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. It is vital that FEMA implement the information collection as soon as possible to support immediate needs in response to the Hermit’s Peak/Calf Canyon Fire. In accordance with the Paperwork Reduction Act (PRA) and the Office of Management and Budget’s (OMB) implementing regulations at 5 C.F.R. § 1320.13: (1) this information is necessary to the mission of the agency, (2) this information is necessary prior to the expiration of time periods established under PRA, (3) public harm is reasonably likely to result if normal clearance procedures are followed, and (4) an unanticipated event has occurred.

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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:
	Not associated with rulemaking

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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: 15

table that charts list of burden

IC Title	Form No.	Form Name
Banking Information - Individuals and Households	FEMA Form FF-104-FY-22-251, FEMA Form FF-104-FY-22-251-A	Banking Information ,   Banking Information (Spanish)
Banking Information - Private Sector	FEMA Form FF-104-FY-22-251, FEMA Form FF-104-FY-22-251-A	Banking Information ,   Banking Information (Spanish)
Banking Information - State, Local & Tribal Governement	FEMA Form FF-104-FY-22-251, FEMA Form FF-104-FY-22-251-A	Banking Information ,   Banking Information (Spanish)
Notice of Loss - Individuals and Households	FEMA Form FF-104-FY-22-230-A, FEMA Form FF-104-FY-22-230	Notice of Loss ,   Notice of Loss (Spanish)
Notice of Loss - Private Sector	FEMA Form FF-104-FY-22-230-A, FEMA Form FF-104-FY-22-230	Notice of Loss ,   Notice of Loss (Spanish)
Notice of Loss - State, Local, and Tribal Governments	FEMA Form FF-104-FY-22-230-A, FEMA Form FF-104-FY-22-230	Notice of Loss ,   Notice of Loss (Spanish)
Partial Payment Release and Certification Form (Entity) - Private Sector	FEMA Form FF-104-FY-22-253, FEMA Form FF-104-FY-22-253-A	Partial Payment Release and Certification Form (Entity) ,   Partial Payment Release and Certification Form (Entity) (Spanish)
Partial Payment Release and Certification Form (Entity) - State, Local and Tribal Governments	FEMA Form FF-104-FY-22-253, FEMA Form FF-104-FY-22-253-A	Partial Payment Release and Certification Form (Entity) ,   Partial Payment Release and Certification Form (Entity) (Spanish)
Partial Payment Release and Certification Form - Individuals and Households	FEMA Form FF-104-FY-22-252, FEMA Form FF-104-FY-22-252-A	Partial Payment Release and Certification Form ,   Partial Payment Release and Certification Form (Spanish)
Proof of Loss - Individuals and Households	FEMA Form FF-104-FY-22-231-A, FEMA Form FF-104-FY-22-231	Proof of Loss ,   Proof of Loss (Spanish)
Proof of Loss - Private Sector	FEMA Form FF-104-FY-22-231-A, FEMA Form FF-104-FY-22-231	Proof of Loss ,   Proof of Loss (Spanish)
Proof of Loss - State, Local, and Tribal Governments	FEMA Form FF-204-FY-22-231-A, FEMA Form FF-204-FY-22-231	Proof of Loss ,   Proof of Loss (Spanish)
Request to Supplement Claim - Individuals and Households	FEMA Form FF-104-FY-22-254-A, FEMA Form FF-104-FY-22-254	Request to Supplement Claim ,   Request to Supplement Claim (Spanish)
Request to Supplement Claim - Private Sector	FEMA Form FF-104-FY-22-254, FEMA Form FF-104-FY-22-254-A	Request to Supplement Claim ,   Request to Supplement Claim (Spanish)
Request to Supplement Claim - State, Local and Tribal Governments	FEMA Form FF-104-FY-22-254, FEMA Form FF-104-FY-22-254-A	Requeset to Supplement Claim ,   Request to Supplement Claim (Spanish)

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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	143,625	57,450	0	86,175	0	0
Annual Time Burden (Hours)	689,401	667,857	0	21,544	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 information collection. Therefore, no historical data is available and all of the estimates in this information collection are new

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Annual Cost to Federal Government: $65,103,002

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: 02/15/2023

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