Form FEMA Form FF-104-F FEMA Form FF-104-F Partial Payment Release and Certification Form

OMB Control No. 1600-0155
Expiration Date: XX/XX/XXXX

DEPARTMENT OF HOMELAND SECURITY

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

RELEASE AND CERTIFICATION - PARTIAL PAYMENT
I, the undersigned, filed a claim pursuant to the Hermit's Peak/Calf Canyon Fire Assistance Act, Pub. L. No. 117-180, 136 Stat. 2114
(the “Act”) for damages resulting from the Hermit's Peak/Calf Canyon Fire (the “Fire”) with the Hermit's Peak/Calf Canyon Claims
Office (the “Office”). Pursuant to Section 104(d)(2) of the Act and after investigation, the Office determined that I suffered a partial
compensable loss on a severable portion of my claim in the amount of $

for my loss as set forth in the attached

Proof of Loss. I acknowledge that a partial payment in the amount set forth above fully satisfies all my outstanding claims against
the Federal Emergency Management Agency and/or the United States for any damage related to the severable portion of my loss. I
agree that the payment is final and conclusive with respect to all the severable portion of my injuries and that by accepting partial
payment in the amount referenced above I am completely and forever releasing the Federal Emergency Management Agency and
the United States from any past and present and future claims related to the severable portion of my loss.

DRAFT

I understand that by signing this Release and Certification - Partial Payment I reserve the right to continue to pursue other claims
under the Act not related to the severable losses identified on the attached Proof of Loss. I further understand that the decision to
provide a partial payment cannot be appealed, but acceptance of a partial payment does not affect my ability to pursue an appeal,
arbitration, or other options under the Act with respect to any portion of a claim for which a Release and Certification Form is not
executed.

This Release and Certification constitutes the complete agreement of the parties and may only be amended by the written
agreement of both myself and the Federal Emergency Management Agency.

I declare under penalty of perjury that the information I have provided regarding my loss is true and correct.
Claimant Signature:

SSN or TIN:

Current
Mailing
Address
Damaged
Property
Address

Printed Name:

Claim Number:

Date Signed:

Phone Number:

Street Address:
City:

State:

Zip Code:

State:

Zip Code:

Street Address:
City:

Enter your email address so you have the option to check your claims status online. If you do not enter your email
address, you will need to contact your Navigator to get updates on your registration.
Email Address (Optional):

FEMA Form FF-104-FY-22-252 (1/23)

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