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

DEPARTMENT OF HOMELAND SECURITY

OMB Control No. 1660-0155
Expiration Date: 05/31/2023

Federal Emergency Management Agency
Hermit's Peak/Calf Canyon Fire Assistance Act

NOTICE OF LOSS - HERMIT'S PEAK/CALF CANYON FIRE
By filing this Notice of Loss, you are choosing to seek compensation for losses from the Hermit's Peak Fire from the United States
through the Hermit's Peak/Calf Canyon Fire Assistance Act (Act), Public Law 117-180, 136 Stat. 2177 (2022).
• In order for the Federal Emergency Management Agency (FEMA) to consider your claim under the Act, you must sign the
Verification of Truth of Information statement on Page 3 of this Notice of Loss.
• FEMA's regulations describing the claims process will be published in the Federal Register and may also be found at
http://www.fema.gov/hermits-peak following publication.
• You may file your Notice of Loss at any time up to 2 years from the date the regulations publish in the Federal Register.
• During the claims process, we will request additional information regarding your losses and you will have an opportunity to
supplement the information listed below.
• Electronically submit, mail, or submit in person the completed Notice of Loss to the FEMA Office of Hermit's Peak/Calf
Canyon Fire Claims.
• For more information, please visit http://www.fema.gov/hermits-peak following publication.

TYPE OF CLAIM
(Please submit a separate Notice of Loss for each type of claim.)

DRAFT

What type of claim are you filing? (check only one option)
Individual or Household
Business
Government

Indian Tribe
Not-for-Profit
Other:

CLAIMANT CONTACT INFORMATION

Name (Entity filing claim, or first, middle initial, last if filing as an individual or household) and contact information:
Name:
Current Address:
City, State, Zip:
Damaged Property Address:
City, State, Zip:
Telephone Number:

Fax No.:

E-mail Address:

What is the best time to reach you?

Claims for Individual or Household: Please provide the following information. If you are filing on behalf of another person or
persons, please include the following information for each person.
What are the claimant's names?
(Including yourself, if you are a claimant)

What is this person's relationship to you?
(examples: self, spouse, child)

Is the claimant a member
of an Indian Tribe?
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If more space is required to identify additional claimants, please attach the information to this Notice of Loss.

FEMA Form FF-104-FY-22-230 (2/23)

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LOSSES
In general terms, describe the loss incurred by the claimant named above. You will be able to supplement this information
during the claims process. Please do not submit documentation at this time. Detailed information on your losses and/or injuries and
their dollar value will be requested and collected later during the claims process.
Loss of property (examples: property loss, decrease in value of real property, damage to physical infrastructure, lost subsistence,
cost reforestation, other.)

Business loss (examples: damage to tangible assets or inventory, business interruption loss, overhead, employee wages, loss of
business net income, other.)

DRAFT

Financial loss (examples: increased mortgage interest cost, insurance deductible, temporary living or relocation expenses, lost
wages or personal income, emergency staffing, debris removal and clean-up, other.)

Personal injury (examples: general damages, medical expenses, injury-related lost wages/personal income)

Additional pages may be attached.

INSURANCE AND OTHER ASSISTANCE

(Responses to these questions will assist us in assigning a claims reviewer and more efficiently process the claim.)
1. Have you filed an insurance claim for losses related to the Hermit's Peak/Calf Canyon Fire (whether or not the claim has
been closed)?
Yes

No

If yes, please provide the name and contact information of the insurance company:

2. Did you receive any FEMA Grants? (examples: Temporary Housing or Individual Assistance, Public Assistance, Mitigation)
Yes

No

3. Did you receive a loan or grant from any of the following?
U.S. Small Business Administration (SBA) Disaster Assistance
U.S. Department of Agriculture (USDA)
Environmental Protection Agency (EPA)
Indian Tribe

Not-for-Profit
State of New Mexico
Other:

4. Will you need a translator or special accommodations during the claims process?
Yes

No

FEMA Form FF-104-FY-22-230 (2/23)

If yes, please describe:
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VERIFICATION OF TRUTH OF INFORMATION
By filing this form all claimants whose names appear on this form attest that:
I declare under penalty of perjury under the laws of the United States that all of my information on this form is true and correct.
Individual completing this form:
Name (Print):

Signature:

For an individual or household claim, all claimants named on this Notice of Loss, except minors, must sign.
For a business, not-for-profit organization, pueblo, or government claim, an authorized official must sign.
Name (Print):

Signature:

Relationship or Title:

Date:

DRAFT
VERIFICATION OF TRUTH OF INFORMATION (Continued)
Complete this section only if you will be represented by a third party representative.
To comply with 6 C.F.R. section 5.21 and allow access to records developed as part of your claim, any third party representative
(including but not limited to attorneys, public adjustors, and family members), must provide the following:
Full Name of Claimant:
Current Address of Claimant:
Place of Birth of Claimant:
Country of Citizenship or Residence of Claimant:
I, the undersigned Claimant, authorize disclosure of records pertaining to my Hermit’s Peak/Calf Canyon Fire Assistance Claim to:
(Name of Representative)

FEMA Form FF-104-FY-22-230 (2/23)

Page 3 of 5

CONSENT TO SHARE DATA WITH THE STATE OF NEW MEXICO
A. I authorize FEMA to release to the entities listed in B. below the following information:
Yes

No

1. My claim file, including amounts of awards, contact information, banking information, Social Security
Number, etc. (Cross out information you do not want to share or list under “Other” and check NO.)

Yes

No

2. My contact information, including address, phone number, email address, work contract information,
FEMA application number, etc. (Cross out information you do not want to share or list under “Other” and
check NO.)

Yes

No

3. Other:

B. If additional resources may be available to me, or if other persons request information regarding my case, I authorize the
information listed in A. above to be released to:
Yes

No

1. State agencies offering assistance for unmet needs.

ADDITIONAL INFORMATION

DRAFT

FEMA Form FF-104-FY-22-230 (2/23)

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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 statute or 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.”

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 45 minutes per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You
are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. 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 20472-3100, Paperwork Reduction Project
(1660-0155) NOTE: Do not send your completed form to this address.

FEMA Form FF-104-FY-22-230 (2/23)

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