Form FF-104-FY-21-122 ( FF-104-FY-21-122 ( Application for Disaster Assistance (paper, English)

DEPARTMENT OF HOMELAND SECURITY

OMB Control No.: 1660-0002
Expiration: 09-30-2025

Federal Emergency Management Agency
APPLICATION FOR DISASTER ASSISTANCE
REC. #
1.

DR #

Loss Date

Name of Applicant (last, first, MI)

3. Applicant Social Security No.

APP. DATE
2. Preferred Name

4. Date of Birth

5. Email

6. Do you have a disability or language need that requires an accommodation to interact with FEMA staff and/or access FEMA
programs?

Yes

No

If Yes, what do you need? (select all that apply)
Sign language interpreter

Language other than English
Spanish – Español
Arabic – ‫اﻟﻌرﺑﯾﺔ‬

CART (Communication Access Real-time
Translation) (in person or remote)
Text messages to communicate

Haitian Creole – Kreyòl Ayisyen

Assistive listening device
Braille

Russian – Русский

Large print

Vietnamese – Tiếng Việt
Samoan – Sāmoa

Face-to-face assistance (reader or writer)
Wheelchair access

Mandarin – 中文
Other

DRAFT
Other

7. Do you or anyone in your household have a disability that affects your ability to perform activities of daily living or requires an
assistive device? (NOTE: An assistive device can include wheelchair, walker, cane, hearing aid, communication device,
service animal, personal care attendant, oxygen, dialysis, etc.)

Yes

No

Yes

No

If Yes, select all that apply:
Mobility

Cognitive/Developmental Disabilities/Mental Health
Hearing/Speech
Vision
Self-Care

Independent Living
Other

Prefer Not to Answer

8. Did you have any disability-related assistive devices or medically required equipment/supplies/support services damaged,
destroyed, lost, or disrupted because of the disaster?
If Yes, select all that apply:

Power/manual wheelchair

Adaptive van/vehicle

Scooter

Walker/cane/crutches

Prosthesis
Oxygen/respiratory equipment

Medication/medical supplies including adult diapers
and catheters

Medical equipment that depends on electricity

Service animal

Assistive technology device for hearing/vision, such
as hearing aid, screen enlarging software, etc.

Personal assistance services/in-home care
Dialysis

Personal-care devices such as shower bench,
bedside commode, Hoyer lift, or lift chair

Other

Environmental control/alerting devices
10. Alternate Phone No.
Phone Type

9. Primary Phone No.
Phone Type:
Note: _____________

. Note:

11 Damaged Dwelling Address
Street with No.
12. Do You:

Own

Apt/Lot

City

State

Zip

Rent

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13. Mailing Address

Same as Damaged Address

Street with No

Apt/Lot

City

State

Zip

In Care of:
14. Damage address county/parish/municipality _________15. Damage Type:
Flood
Hurricane/Hail/Rain/Wind Driven Rain

Seepage
Sewer Backup

Earthquake
Fire/Lava Flow/Ash

Power Surge/Lightning

Tornado/Wind

Ice/Snow

16. Home Damage?
Yes

No

17. Personal Property Damage
(not including vehicles)?
Yes

Unknown

No

Unknown

Primary Residency?
Yes
No
20 Vehicle Damage?
Yes
No

21. Need for food, clothing,
shelter, gas, medication, or
medical equipment?
Yes
No

24. Medical expenses?
Yes
No

Other

18. Essential Utility Needs?
Yes
No

19. Access damage?
Yes

No

Utilities Out 3 days or more?
Yes
No
Utilities out now?
Yes
No
22 New or additional childcare
costs?
Yes

23. Lodging Expenses?
Yes
No
Received Assistance with temporary
lodging expenses?
Yes
No
25. Miscellaneous Expenses?
Yes
No

No

Funeral Expenses?
Yes
No

DRAFT

Dental Expenses?
Yes
No

26. Level of Damage to Home or Personal Property (Select One):

Minor damage but able to live in home
Damage to Home/Personal Property and may not be able to live in home.

Home was destroyed
Unknown

Damage to Home/Personal Property requires major repairs. Not able to live in home.
27. Current Location (Select One)?
My Home
Family/Friends

Mass Shelter
Church/House of Worship

FEMA Provided Unit
New Permanent Rental

Purchased New Home
Place of Employment

Secondary Residence
My Vehicle

Hotel/Motel

Homeless

New Temporary Rental

RV/Camper

Tent

28. Type of Home (Select One)?
Home-Single/Duplex
Mobile Home

Condo
Apartment

Assisted Living Facility
Boat

Correctional Facility
Military Housing

Townhouse

Travel Trailer

College Dormitory

Other

29. Currently able to get to your home (Select One)?
Yes, able to get to and leave home.
No, due to flooding or damages to roads or bridges in the area
No, due to damage of a privately owned road, bridge, or dock.
No, due to my medical or accessibility features are damaged (such as a ramp or elevator, etc.)
No, due to mandatory evacuation
30. Need for Moving and Storage Expenses after the disaster?
Yes
No

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31. Home/Personal
Property Insurance
Type

32 How many vehicles in your household?

Insurance Company Name

After the disaster, how many are drivable?
Did any damaged vehicles have disability related accessibility features?
Yes No
Are any damaged vehicles covered by comprehensive (full coverage)
insurance?
Yes No

I have no insurance for my home or personal property
33. Disaster Related Vehicle Damage
Vehicle Information
Year

Make

34. Emergency Needs:

Damaged?
Model

YES

NO

Drivable?
YES

NO

Comprehensive
Liability
Insurance?
Insurance?
YES

NO

Food, Medication, Durable Medical Equipment or Gas

YES

NO

Shelter

Registered?

Insurance
Company
Name

YES

NO

Clothing

35. Persons living in your home at time of disaster

DRAFT
Last Name

First Name

MI

Social Security Number
(App and Co-App Only)

Relationship

Age

36. Financial

Household’s source of income is self-employment?

Yes

No

Own a business or rental property affected by the disaster?

Yes

No

37. No. of Dependents (including yourself)

39. Electronic Funds Transfer

Yes

38. Family’s pre-disaster income before taxes are deducted $
Income not available

40. Correspondence language?

No

English

Bank/Financial Institution Name:
Account Type:

Checking

41 Traditional postal mail or electronic
notification?

Savings

Routing No. (9 digits):
42. Receive text messaging updates?
Yes
No
Mobile Phone No.

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
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Spanish

Account No.:

Postal Mail

Agree to text messaging terms?

Email

Yes

No

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37. Comments

38. FEMA Representative

DRAFT
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Application for Disaster Assistance Instructions
It’s important you understand that your application becomes a legal document. FEMA may use external sources to verify the accuracy of the information you
enter.
Assessment Section:
What Help do you Need:
Home or Property damage
o
Home Damage,
o
Personal Property Damage
o
Vehicle Damage
Other Expenses
o
Funeral or reburial expenses
o
Lodging expenses
o
Medical or dental expenses
o
New or extra childcare expenses
o
Miscellaneous Item expenses
Emergency Needs
o
Food, clothing, shelter, gas, medication, or medical equipment
Essential utilities
o
o
Home access
Business
Unemployment

•

•

•

•
•
Referrals

DRAFT

Do NOT complete an application for Business Needs ONLY
You may be able to get assistance from the U.S. Small Business Administration (SBA) for business losses.
Provide referrals to ‘SBA Disaster Assistance’ for Business ONLY.
Do NOT complete an application for Unemployment Needs ONLY.
You may be able to get assistance from your state’s unemployment office.
Provide referrals to the ‘Career One Stop’ Unemployment program for your state.

For other needs outside of FEMA Individuals and Households Program (IHP) Assistance contact 211/United Way referral.
Is this your primary home or secondary home?
•
Primary – live more than 6 months out of the year
•
Secondary – vacation or second home

Secondary Home – for some assistance FEMA can only provide assistance for your primary home.
You may continue with your application.

Representative:
As a FEMA representative, you must take steps to ensure that you protect what you collect. Physically secure hard copies of documents containing PII in a
locked file drawer, cabinet, or safe. Do not leave documents with PII unattended on printers, fax machines, copiers, or desktops. Cross shred paper
containing PII; do not recycle or place in garbage containers.

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Instructions for completing the application
Representative: Complete the Record Information ensuring you have the correct disaster number and date of loss.
Complete Personal Information
1.

Enter the last name, first name, and middle initial of applicant. Enter JR, SR, III, etc. following the last name if applicable. If the application is for
Funeral ONLY, enter the name of the person responsible for the funeral expenses.

2.

Enter the applicant’ preferred name.

3.

Enter applicant's Social Security Number (SSN). If the applicant does not have an SSN but has a dependent child with an SSN, enter the child’s
SSN and information in fields 1-5. If the application is for Funeral ONLY, enter the SSN of the person responsible for the funeral expenses.

4.

Enter applicant’s date of birth.

5.

Enter applicant’s e-mail address, if available.

Language Information
6.

Accommodation or assistance may include, but is not limited to, sign language interpreter, Braille, large print, accessible electronic format, or
materials in a language other than English. FEMA programs may include, but are not limited to, home inspection, town hall meetings, access to a
Disaster Recovery Centers, or accessible temporary housing (if eligible). Check Yes or No accordingly.. If Yes, check all needs that apply.

Other Needs Information
7. The Americans with Disabilities Act (ADA) defines disability as "a physical or mental impairment that substantially limits one or more of the major life
activities of such individual." 42 USC 12102(2) (A). If the applicant or household member has such a disability, check Yes. If Yes, check all that
apply or Prefer Not to Answer.
8.

DRAFT

If the applicant or household member had any disability-related assistive devices or medically required equipment/supplies/support services
damaged, destroyed, lost or disrupted because of the disaster, check Yes and check all that apply.

Phone Numbers

Representative: If the applicant uses a video relay service (VRS), captioned
telephone (CTS), or other service, give FEMA the number for that service.

9.

Primary Phone: Beginning with the area code, enter the phone number used at the damaged dwelling at the time of the disaster, and enter the type
of phone. Use the Note field if specific contact information is needed.

10. . Alternate Phone: Enter an alternate phone number and type of phone where FEMA can reach the applicant or leave a message, if applicable.
Use the Note field if specific contact information is needed (i.e. family member’s phone number, neighbor, minister, etc.).

Address

11. Enter the full physical street address where the damage occurred, including the house, or building number, street name and any apartment or lot
number (exactly as it appears on a utility bill). Do not use any abbreviations, do not enter a “#” symbol, and do not enter a PO Box or general
delivery address.

12. If the applicant is named on the deed, or applicant maintains the home, pays no rent and pays taxes, or has lifetime occupancy rights while not
holding the legal title to the home, check Own.

If the applicant does not meet any of the ownership criteria, even if the applicant pays no rent, check Rent.13. Check Same as Damaged Address,
if applicable. If different, enter the address where the applicant is currently receiving mail. A PO Box or general delivery address may be used. If
mail is received in care of another person, add that person’s name.14. Enter the county/Parish/Municipality where the damage occurred.

Losses
Representative: Only record losses or needs of the applicant in the following
section
15. Check all damage types that apply. Other may include explosion, drought, riot, etc.
16. Check Yes if the applicant’s home was damaged by the disaster. Check No if no damage to the applicant’s home or if the applicant is applying for
Transportation, or Funeral ONLY. Check Unknown if the applicant is unsure of the damage to the home.
If Home damage selection is Yes, or Unknown, check Yes if the affected home is the applicant’s primary residence (where the applicant lives
more than 6 months of the year, listed the address on their Federal Tax Return, or files a homestead exemption at the address). Check No if
the affected home is a secondary residence or vacation home, or if the application is, Transportation, or Funeral ONLY 17. Check Yes if the
applicant had personal property damage (i.e. appliances, clothing, and/or furniture).Check No if no damage to the applicant’s personal property,
or if the applicant is applying for Transportation, or Funeral ONLY. Check Unknown if the applicant is unsure of personal property damage.
18. Check Yes if the applicant has essential utility needs.
Check Yes if the applicant has been without essential utilities for 3 days or more.
Check Yes if the utilities are out now (time of application)
19. Check Yes if the applicant has trouble accessing the home. (Example: Blocked Entry, or damage to accessibility equipment like a ramp)
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FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
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20. Check Yes if the applicant has vehicle damage.
21. Check Yes if the applicant has a need for food, clothing, shelter, gas, medication, or medical equipment.
22. Check Yes if the applicant has any new or additional child care costs because of the disaster.
23. Check Yes if the applicant has any lodging expenses (Example: Hotel, Motel, etc.)
If Yes, did the applicant get assistance with temporary lodging expenses from any other source.
24. Check Yes if the applicant has any Medical expenses as a result of the disaster.
Check Yes if the applicant has any Dental expenses as a result of the disaster.
Check Yes if the applicant has any Funeral expenses as a result of the disaster.
Representative: If the applicant has any disaster caused funeral expenses include the deceased in the Occupants tab with the relationship
‘deceased’. The social security and date of birth is needed for the deceased.
25. Check Yes if the applicant has any Miscellaneous expenses as a result of the disaster. (Example; Dehumidifier, chainsaw, etc)
26. If the applicant reports home or personal property damages, check the level of disaster damage to applicant’s home and/or personal property that
best applies based on the provided options.

DRAFT
27. Check the location where the applicant is currently living or staying.
28. Check the residence type for which the applicant is applying.
29. Check Yes if the applicant is able to both get to and leave the home, or if the application is, Transportation, or Funeral ONLY. If the applicant is
unable to access the home, check the reason.
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30. Check Yes if the applicant needs help with moving and storage expenses after the disaster.
31. List all types of insurance the applicant held at the time of the disaster for the home and/or personal property, including but not limited to sewer
backup, earthquake, and/or flood, and the insurance company name.
Check I have no insurance for my home or personal property if there was no insurance coverage for the home or personal property losses.
32. If the applicant had vehicle damages, how many vehicles does the household have, only include those that were drivable before the disaster.
How many were drivable after the disaster. Did any of the damaged vehicles have disability related accessibility features (Example: Wheelchair
lifts and ramps, pedal or seat belt extenders, hand control and steering devices, etc.)
Did any of the damaged vehicles have disability related accessibility features (Example: Wheelchair lifts and ramps, pedal or seat belt extenders, hand
control and steering devices, etc.)
Were any of the damaged vehicles covered by comprehensive (full coverage) insurance?
33. Enter all vehicles owned by the applicant or anyone in the household. Year: Enter the year the vehicle was manufactured. Make: Enter the
vehicle make. Model: Enter the vehicle model. Damaged: Check Yes or No to indicate if the vehicle was damaged by the disaster (if unknown,
check No). Drivable: Check Yes or No to indicate if the vehicle is currently drivable (if unknown, check No). Comprehensive Insurance: Check
Yes or No to indicate if the vehicle is covered by comprehensive insurance. Liability Insurance: Check Yes or No to indicate if the vehicle is
covered by liability insurance (if unknown, check No). Enter the insurance company name if the vehicle is covered by comprehensive or liability
insurance. Registered: Check Yes or No to indicate if the vehicle is registered.
34. Check each emergency need (essential items for day-to-day existence). Emergency needs do not include stored food.

Occupants
35. Enter the information for the applicant and all persons who considered the home to be their primary residence at the time of the disaster, whether
or not they are related to the applicant. Include the SSN for only the applicant and co-applicant (if applicable). Representative: If there are
funeral expenses, include the deceased name, SSN, and date of birth.

DRAFT

36. Check Yes or No to indicate whether the household’s primary source of income is from self-employment. Check Yes or No to indicate whether
the applicant owns or represents a business or rental property affected by the disaster.
37. Enter the number of dependents, including the applicant and those listed as dependents on their Federal Tax Return.

38. Enter the pre-disaster household annual gross income (the total household income before any deductions are subtracted, including income
from welfare, child support, stocks, interest, and/or annuities. DO NOT include food stamps or HUD Section 8 assistance). If the applicant is
"living off savings, family, or friends," enter the approximate amount they receive yearly. Enter whole dollars only, no symbols or decimal
points.
39. If the applicant is found eligible for FEMA assistance and would like funds directly deposited into their bank account, check Yes. If Yes, enter
the name of the applicant's financial institution, their 9-digit routing number (the 9-digit number that appears in the lower left corner of a check),
the account type, and the applicant's account number (found at the bottom of a check immediately after the routing number). NOTE: Applicant’s
name must be on the account.

Correspondence

40. Check the language in which the applicant prefers to receive FEMA correspondence.

41. Check the form of communication through which the applicant prefers to receive FEMA correspondence.
Representative: If the applicant chooses to receive email updates, they will not receive any postal mail. They must have a disaster assistance
account at DisasterAssistance.gov to receive email updates. Verify the email address entered in field 6.

42. Text messaging is an optional service. Check Yes if the applicant wants to receive text message status alerts in addition to e-mail or postal
mail. If Yes, enter the mobile phone number through which the applicant would like to receive text messages. Check Yes or No to indicate if the
applicant agrees to the terms of text messaging (FEMA text messages do not replace postal mail or e-mail; FEMA’s text messaging number is
4FEMA [43362]. Please note you may also receive a text message from a FEMA inspector to schedule an appointment for your inspection;
Standard text message rates apply.).
Representative: Capture demographic information on the FEMA Form FF-256-FY-21-100- Equity Demographics Questions.
43. Enter any comments.
44. Enter name of the FEMA representative filling out the form

PRIVACY NOTICE
AUTHORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records within this system under the authority of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act (the Stafford Act), Pub. L. No. 93-288, as amended, 42 U.S.C. §§ 5121-5207; 6 U.S.C. §§ 776-77, 795;
the Debt Collection Improvement Act of 1996, 31 U.S.C. §§ 3325(d), 7701(c)(1); the Government Performance and Results Act, Pub. L. No. 103-62, as
amended; Reorganization Plan No. 3 of 1978; Executive Order 13411, “Improving Assistance for Disaster Victims,” August 29, 2006; and Executive
Order 12862 “Setting Customer Service Standards,” September 11, 2003, as described in this notice.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administrating financial assistance
under a Presidentially-declared disaster. Additionally, information may be reviewed internally within FEMA for quality assurance purposes and used to
assess FEMA's customer service to disaster assistance applicants. FEMA collects the social security number (SSN) to verify an applicant's identity and
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to prevent a duplication of benefits.
ROUTINE USE(S): FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their disaster assistance files
outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. FEMA may share the personal information of
non-citizens, as permitted by the following Privacy Impact Assessments: DHS/FEMA/PIA-012(a) Disaster Assistance Improvement Plain (DAIP) (Nov.
16, 2012); DHS/FEMA/PIA-027 National Emergency Management Information System - Individual Assistance (NEMIS-IA) Web-based and Client-based
Modules (June 29, 2012); DHS/FEMA/PIA-015 Quality Assurance Recording System (Aug. 15, 2014). This includes sharing your personal information
with federal, state, tribal, local agencies and voluntary organizations to enable individuals to receive additional disaster assistance, to prevent duplicating
your benefits, or for FEMA to recover disaster funds received erroneously, spent inappropriately, or through fraud as necessary and authorized by
routine uses published in DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records, 78 Fed. Reg. 25,282 (Apr.30, 2013) and
upon written request, by agreement or as required by law.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: The disclosure of information, including the SSN, on this form is voluntary; however,
failure to provide the information requested may delay or prevent the individual from receiving disaster assistance.

PAPERWORK BURDEN DISCLOSURE NOTICE 009-0-1 (Paper Application)
Public reporting burden for this data collection is estimated to average 18 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. This collection of
information is required to obtain or retain benefits. 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 St. SW, Washington, DC 20472-3100,
Paperwork Reduction Project (1660-0002) NOTE: Do not send your completed form to this address.

DRAFT
FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
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