#4 Generic Application-Notice of Loss

Request for Approval under the
“Generic Clearance for Notice of Loss and Proof of Loss”
(OMB Control Number: 1660-0159)

TITLE OF INFORMATION COLLECTION: FF-104-FY-22-230 Notice of Loss (NOL)
(English) & FF-104-FY-22-230-A Notice of Loss (NOL) (Spanish)
PURPOSE: Use of FEMA Form FF-104-FY-22-230 serves to structure the information
concerning the injuries sustained by claimants and formally begins the claims process. Each item
of information requested is needed to establish the nature and scope of the claimant’s injuries
and assign a Claims Reviewer to begin review of the claim, while also ensuring election of the
Act’s process for compensation. The information requested includes Claimant information
(name, contact information including phone number, email address, and physical address); type
of claim (individual/household, business, government, Indian Tribe, non-profit, other);
description of losses in general terms (loss of property, business loss, financial loss); insurance
information (company name, whether a claim has been filed with the company); FEMA grants
received; other government assistance (Federal, State, local, Tribal); special needs assistance;
translation assistance; and an attestation choosing the Act’s process as the method of resolving
claims against the Federal government.

DESCRIPTION OF RESPONDENTS: The target group for this information collection
comprises individuals, households, and entities directly affected by a fire. These respondents
include those who have experienced the impact of fire on their homes, livelihoods, and over-all
well-being. The aim is to engage with those who have first-hand knowledge of the challenges,
losses, and needs resulting from a fire.
Key Characteristics of the Respondents:
1. Residential Impact: Individuals who have seen their homes directly impacted by the fire,
whether through damage, destruction, or evacuation.
2. Economic Impact: Households that may have experienced economic setbacks due to the fire,
including disruptions to employment, business operations, or income sources.
3. Community Engagement: Individuals actively involved in the affected community, fostering a
community-centric approach to understanding the collective impact and needs.
4. Varying Demographics: Respondents may represent diverse demographic profiles, including
age, income levels, family structures, and cultural backgrounds.
5. Multi-Household Dynamics: Understanding the dynamics of households, especially those with
varying family structures or shared living arrangements, to tailor assistance and support
accordingly.
6. Specific Needs: Identification of specific needs arising from the fire, such as immediate
housing, financial support, healthcare, or emotional well-being.
7. Geographic Location: Recognizing the geographical dispersion of impacted individuals and
households to ensure a comprehensive understanding of the varied challenges faced.
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TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[ ] Customer Satisfaction Survey
[ ] Small Discussion Group
[ X ] Other: Claims Processing_

CERTIFICATION:
I certify the following to be true:
1. The collection is required to obtain benefits.
2. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
3. FEMA needs to collect necessary information to perform these activities.
4. Usability testing has been completed on this instrument.
Digitally signed by TYLER C

Digital Signature:
To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ X ] Yes [ ] No
2. If Yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974? [ X ] Yes [ ] No
3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X ] No
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ X ] No
BURDEN HOURS: The estimated annual burden hours to respondents is 21,543 hours.
Category of Respondent
Individuals/Households
State, local, and Tribal Government
For-Profit Businesses and Not-For-Profit Institutions
Totals

No. of
Respondents
9,479
287
18,959

Participation
Time
.75
.75
.75

Burden
7,109
215
14,219
21,543

FEDERAL COST: The estimated annual cost to the Federal government is $1,448,682.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:

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The selection of your targeted respondents
1. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
[ ] Yes [ ] No
If the answer is yes, please provide a description of both below (or attach the sampling plan)? If
the answer is no, please provide a description of how you plan to identify your potential group of
respondents and how you will select them?
Response:

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ ] Web-based or other forms of social media
☒ Telephone
☒In-person
☒ Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [X ] Yes [ ] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

Instructions for completing Request for Approval under the “Generic
Clearance for Notice of Loss and Proof of Loss”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g. Comment card for soliciting feedback on xxxx)
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include this in your explanation.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
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Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal
governments; or (4) Federal Government. Only one type of respondent can be selected.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses and the
participation time and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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