FEMA Form FF-104-F Banking Information Form (English)

OMB Control No. 1600-0159
Expiration Date: XX/XX/XXXX

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
Hermit's Peak/Calf Canyon Claims Office

BANKING INFORMATION FORM
CLAIMANT CONTACT INFORMATION
Name:
Street:
City, State, Zip:
Phone Number:

E-mail Address:

Claim Number:

Date:

DRAFT
CLAIMANT BANKING INFORMATION

(This statement affirms that the undersigned individual is the intended recipient and payee for the forthcoming check)
Payment Option:

Single Payee

Electronic Funds Transfer:

Yes

Multiple Payee

Joint Account

No

Paper Check:

Yes

No

Bank/Financial Institution Name:
Account Type:

Checking

Routing Number (9 digits):

Savings

Account Number:

Send Check to (Address):

**Note: All claimants that have signed the POL are required to input their social security number below.**
Claimant Social Security Number:

Date:

Claimant Social Security Number:

Date:

Claimant Social Security Number:

Date:

Claimant Social Security Number:

Date:

FEMA Form FF-104-FY-22-251 (12/23)

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