Partial Payment Release and Certification Form - Individuals and Households

Notice of Loss and Proof of Loss

Documents and Forms

Document Name Document Type
Form FEMA Form FF-104-F Partial Payment Release and Certification Form - Individuals and Households Form and Instruction
Form FEMA Form FF-104-F Partial Payment Release and Certification Form - Individuals and Households Form and Instruction
FEMA Form FF-104-F Partial Payment Release and Certification Form FEMA Form FF-104-FY-22-252_DRAFT.pdf www.fema.gov/hermits-peak Form and Instruction
FEMA Form FF-104-F Partial Payment Release and Certification Form FEMA Form FF-104-FY-22-252_DRAFT.pdf www.fema.gov/hermits-peak Form and Instruction
FEMA Form FF-104-F Partial Payment Release and Certification Form (Spanish) FEMA Form FF-104-FY-22-252-A_DRAFT.pdf www.fema.gov/hermits-peak Form and Instruction
FEMA Form FF-104-F Partial Payment Release and Certification Form (Spanish) FEMA Form FF-104-FY-22-252-A_DRAFT.pdf www.fema.gov/hermits-peak Form and Instruction

Information Collection (IC) Details

IC Title:	Partial Payment Release and Certification Form - Individuals and Households	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FEMA Form FF-104-FY-22-252	Partial Payment Release and Certification Form	FEMA Form FF-104-FY-22-252_DRAFT.pdf	https://www.fema.gov/hermits-peak	Yes	Yes	Fillable Fileable Signable
Form and Instruction	FEMA Form FF-104-FY-22-252-A	Partial Payment Release and Certification Form (Spanish)	FEMA Form FF-104-FY-22-252-A_DRAFT.pdf	https://www.fema.gov/hermits-peak	Yes	Yes	Fillable Fileable Signable

Line of Business: Disaster Management

Subfunction: Disaster Repair and Restore

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,479	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,479	9,479
Annual IC Time Burden (Hours)	2,370	2,370
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.