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

OMB Control No. 1660-0002
Expiration Date: 8/31/2022

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
APPLICATION FOR DISASTER ASSISTANCE
REC. #
1. Name of Applicant (last, first, MI)
3. Applicant Social Security No.

Disaster #

4. Date of Birth

Loss Date
2. Preferred Name

APP. DATE

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

Yes

Language other than English

CART (Communication Access Real-time
Translation) (in person or remote)

Spanish – Español
Arabic – ‫اﻟﻌرﺑﯾﺔ‬

Text messages to communicate
Assistive listening device

Haitian Creole – Kreyòl Ayisyen
Russian – Русский

Braille
Large print
Face-to-face assistance (reader or writer)

Vietnamese – Tiếng Việt
Samoan – Sāmoa

DRAFT

Wheelchair access
Other

No

Mandarin – 中文
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
Scooter

Adaptive van/vehicle
Walker/cane/crutches

Prosthesis
Oxygen/respiratory equipment
Medical equipment that depends on electricity

Medication/medical supplies including adult diapers
and catheters

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

Personal assistance services/in-home care
Dialysis
Other

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

Service animal

Environmental control/alerting devices
9. Primary Phone No.
Phone Type:
Note:

10. Alternate Phone No.
Phone Type:
Note:

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

Own

Apt/Lot

City

State

Zip

Rent

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
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13. Mailing Address
Street with No.

Same as Damaged Address
Apt/Lot

City

State

Zip

In Care of:
14. Damage address county/parish/municipality:
15. Damage Type:
Flood
Hurricane/Hail/Rain/Wind Driven Rain
Power Surge/Lightning
Other

No

Unknown

20. Vehicle Damage?
Yes

No

Sewer Backup
Tornado/Wind

No

Ice/Snow

21. Need for food, clothing, shelter, gas,
medication, or medical equipment?
Yes

16. Home Damage?
Yes
No
Unknown
Primary Residency?
Yes

Earthquake
Fire/Lava Flow/Ash

18. Essential Utility Needs?
Utilities out 3 days or more?
Utilities out now?

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

Seepage

Yes
Yes

No
No

Yes

No

Unknown

22. New or additional
childcare costs?

No

Yes

19. Access Damage?
Yes
No

Unknown
Unknown

No

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

No

DRAFT

24. Medical Expenses? Dental Expenses?
Yes
No
Yes
No

Funeral Expenses?
Yes
No

25. Miscellaneous Expenses?
Yes
No

26. Level of Damage to Home or Personal Property:
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?
My Home
Family/Friends
Hotel/Motel

Mass Shelter
Church/House of Worship
Homeless

FEMA Provided Unit
New Permanent Rental
New Temporary Rental

Purchased New Home
Place of Employment
RV/Camper

Secondary Residence
My Vehicle
Tent

28. Type of Home?

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?
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

31. Home/Personal Property Insurance
Insurance Type

No

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

Damaged?
Model

YES

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(12/23)

NO

Drivable?
YES

NO

Comprehensive
Liability
Insurance?
Insurance?
YES

NO

YES

NO

Insurance Company
Name

Registered?
YES

NO

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34. Emergency Needs:

Food, Medication, Durable Medical Equipment or Gas

Shelter

Clothing

35. Persons living in your home at time of disaster
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)

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

DRAFT

39. Electronic Funds Transfer

Yes

40. Correspondence language?
English
Spanish

No

Bank/Financial Institution Name:
Account Type:

Checking

41. Traditional postal mail or electronic
notification?

Savings

Routing No. (9 digits):

Account No.:

42. Receive text messaging updates?
Yes
No
Mobile Phone No.
43. Comments

Postal Mail

Agree to text messaging terms?

Email

Yes

No

44. FEMA Representative

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(12/23)

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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

DRAFT

• Emergency Needs
o Food, clothing, shelter, gas, medication, or medical equipment
o Essential utilities
o Home access
• Business

• Unemployment
Referrals

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 shredpaper
containing PII; do not recycle or place in garbage containers.

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(12/23)

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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.

DRAFT
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. 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.

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(12/23)

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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).
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.

DRAFT

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:
I had minor damage, but I am able to live in my home.
• Some damaged or missing roof shingles, siding, gutters, etc.
• Some cracked or broken window glass.
• Minor cracks in floor, walls, or ceilings.
• Flood water or sewer backup entered by home, but was less than 3 inches deep.
• You need(ed) to purchase cleaning supplies and equipment to clean and sanitize your home OR hire(d) a professional to do so.
I had damage to my home or personal property that requires a lot of repairs. I may not be able to live in my home.
• Flood water entered my home, and was between 3 inches and 2 feet deep.
• Damage to roof covering (shingles or metal) that resulted in interior damage.
• Damage to exterior doors, windows, siding, or foundation.
• Damage to well, septic, or HVAC (central air and heat). Debris or over-hanging trees that prevents safe access to my home.
• Loss of or repair to some household appliances or furnishings.
I had damage to my home or personal property that requires major repairs. I am not able to live in my home.
• Flood water was above 2 feet deep on first occupied floor.
• Major structural damage to roof, ceilings, walls, or foundation.
• Private road or bridge damage that prevents access to my home.
I had damage to my home or personal property that requires major repairs. I am not able to live in my home.
• Flood water was above 2 feet deep on first occupied floor.
• Major structural damage to roof, ceilings, walls, or foundation.
• Private road or bridge damage that prevents access to my home.
• An immediate threat to the stability of the home due to land slide or erosion.
• Lost most or all appliances and furnishings.
My home was completely destroyed.
• Home was leveled or completely collapsed.
• Home was washed away.
• Home was burned to the ground.
Unknown
• Unsure which category best describes my damages.
• Mandatory evacuation and don't know damages.
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.

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

DRAFT

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.
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.

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(12/23)

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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
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.

DRAFT

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.

FEMA Form FF-104-FY-21-122 (formerly 009-0-1)
(12/23)

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