Form FF-104-FY-21-128 ( FF-104-FY-21-128 ( Declaration and Release Form (English)

DEPARTMENT OF HOMELAND SECURITY

OMB. No. 1660-0002
Expires March 31, 2024

Federal Emergency Management Agency
DECLARATION AND RELEASE

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 2 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 Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0002)
NOTE: Do not send your completed form to this address.
PRIVACY ACT STATEMENT
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 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, including pursuant to 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.
FEMA may share the personal information of non-citizens, as described in 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) Webbased and Client-based Modules (June 29, 2012); DHS/FEMA/PIA-015 Quality Assurance Recording System (Aug. 15, 2014). FEMA may share 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.
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.

DECLARATION AND RELEASE
In order to be eligible to receive FEMA Disaster Assistance, a member of the household must be a citizen, non-citizen national or qualified alien
of the United States. Please read the form carefully, sign the sheet and return it to the Inspector, and show him/her a current form of
photo identification. Please feel free to consult with an attorney or other immigration expert if you have any questions.
I hereby declare, under penalty of perjury that (check one):
I am a citizen or non-citizen national of the United States.
I am a qualified alien of the United States.
I am the parent or guardian of a minor child who resides with me and who is a citizen, non-citizen national or qualified
alien of the United States. Print full name and age of minor child:
By my signature I certify that:
* Only one application has been submitted for my household.
* All information I have provided regarding my application for FEMA disaster assistance is true and correct to the best of my knowledge.
* I will return any disaster aid money I received from FEMA or the State if I receive insurance or other money for the same loss, or if I do not use FEMA
disaster aid money for the purpose for which it was intended.
I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain disaster aid, it is a violation
of
federal and State laws, which carry severe criminal and civil penalties, including a fine up to $250,000, imprisonment, or both (18 U.S.C. §§ 287, 1001,
and 3571).
I understand that the information provided regarding my application for FEMA disaster assistance may be subject to sharing within the Department of
Homeland Security (DHS) including, but not limited to, the Bureau of Immigration and Customs Enforcement.
I authorize FEMA to verify all information given by me about my property/place of residence, income, employment and dependents in
order to determine my eligibility for disaster assistance; and
I authorize all custodians of records of my insurance, employer, any public or private entity, bank financial or credit data service to release
information to FEMA and/or the State upon request.

NAME (print)

SIGNATURE

DATE OF BIRTH

INSPECTOR ID #

FEMA APPLICATION #

DISASTER #

ADDRESS OF DAMAGED PROPERTY
FEMA Form FF-104-FY-21-128 (formerly 009-0-3)
(03/21)

CITY

STATE

DATE SIGNED

ZIP CODE