Form FEMA Form FF-104-F FEMA Form FF-104-F Pre-Approval Request

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No.
Expiration Date: XX/XX/XXXX

REPORTING REQUIREMENTS FOR NON-CONGREGATE SHELTERING
PAPERWORK BURDEN DISCLOSURE
Public reporting burden for this data collection is estimated to average 30 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 in the upper right corner
of 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, Paperwork Reduction Project
(1660-0017) NOTE: Do not send your completed form to this address.

DRAFT
PRIVACY ACT STATEMENT

The collection of this information is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 402-403, 406-407, 417, 423, 427, 428,
502, and 705; 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e, 5189f, 5192, 5205; “Public Assistance Project Administration §,” 44 C.F.R. 206 Subpart G; and 2
C.F.R. § 200. This information is being collected to provide assistance to eligible jurisdictions and organizations to facilitate the response to and recovery from a
Presidentially-declared disaster or emergency, or to provide assistance for hazard mitigation measures during the recovery process. The disclosure of information
on this form is voluntary; however, failure to provide the requested information may delay or prevent the agency from receiving funds from FEMA’s Public
Assistance program.
PURPOSE AND APPLICABILITY

FEMA provides Public Assistance funding to states, tribes, territories and local governments for emergency protective measures to address immediate threats to
life, public health, and safety caused by a Presidentially declared Emergency or Major Disaster Declaration. Emergency protective measures includesheltering
displaced disaster survivors. Generally, the need for sheltering is met through congregate sheltering. A congregate shelter is any private or public facility that
provides contingency congregate refuge to disaster survivors who have been evacuees or otherwise displaced from their primary residence by a disaster incident,
but day-to-day serves a non-refuge function. Typically, this type of sheltering occurs in facilities with large open spaces, such as schools, churches, community
centers, armories, or other similar facilities. In limited circumstances, such as when congregate shelters are not available or sufficient to meet demand for shelter
services, FEMA may reimburse eligible costs related to emergency sheltering in non-congregate environments.
Recipients and Applicants should use PA Grants Portal to submit all documentation and information to FEMA. Questions are displayed in an intuitive manner to
show the information and documentation needed based on answers provided. All signatures are official and legally binding.
The following information is needed to complete this form:
• Sheltering specifics (e.g., intake, registration, and daily operation information for each open shelter).

FEMA Form FF-104-FY-22-238 (11/23)

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SECTION I - APPLICANT INFORMATION
Declaration #

Legal Name

FEMA PA ID:
SECTION II - REPORTING REQUIREMENTS

Reporting Period:
Identification Information
FEMA
Registration
ID

Personal
ID
number

Head of Household Information

First Name

Household
Size

Number of
individuals
Phone Number
in the
Household

Damaged Dwelling Information
Street
Address

Post-incident
Residence
State Zip Code
Habitability
Status1

Shelter Information
Shelter
Site
ID
number

DRAFT

Last Name

City

Shelter
Check in
date

Shelter
Check out
date

1 Help

Text – Per the Emergency Non-Congregate Sheltering Memo issued on 6/28/2022, the Applicant may determine a household’s habitability status using IA information, Home
Assessment information, or a habitability assessment process developed by the Applicant. The Applicant must submit the habitability determination method with the time extension
request. Additionally, the Applicant should maintain information about the basic habitability of each individual and household in NCS during the period for which the Applicant is
requesting a time extension.

FEMA Form FF-104-FY-22-238 (11/23)

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Identification Information
FEMA
Registration
ID

Personal
ID
number

Head of Household Information

First Name

Last Name

Household
Size

Number of
individuals
Phone Number
in the
Household

Damaged Dwelling Information
Street
Address

City

Post-incident
Residence
State Zip Code
Habitability
Status1

Shelter Information
Shelter
Site
ID
number

Shelter
Check in
date

Shelter
Check out
date

DRAFT
NON-CONGREGATE SHELTERING
I certify that the incident’s impact is beyond the capability of the Applicant and Recipient to effectively manage emergency sheltering needs without conducting
non-congregate sheltering.
I acknowledge to inform FEMA if other recovery resources are not sufficient to transition identified disaster survivors due to known and documented disastercaused housing challenges.
I acknowledge that the criteria for each disaster survivor household (individuals and households) served by non-congregate sheltering meets the following:
• Each household is in an IA designated county/parish/jurisdiction;
• Each household has registered with FEMA IA program for disaster assistance;
• Each household has not requested to withdraw its FEMA registration
• The Applicant has determined that the home (primary residence) is not habitable; and
• The Applicant has determined the household is able to document status as an owner or renter of the home (primary residence) pre-incident
FEMA Form FF-104-FY-22-238 (11/23)

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I acknowledge that FEMA expects all Applicants performing non-congregate sheltering develop a data management component that captures specific information
regarding individuals/households when conducting non-congregate sheltering operations to ensure eligible work criteria is met and prevent duplication of benefits.
The information collected should contain the following data points:
• FEMA Registration ID (if available)
• Head of Household: First Name
• Head of Household: Last Name
• Head of Household: Mobile or other phone number
• Number of individuals in the Household
• Damaged Dwelling: Street Address
• Damaged Dwelling: City
• Damaged Dwelling: State
• Damaged Dwelling: Zip Code

DRAFT

• Post-incident residence habitability status
• Number of rooms
• Shelter Check in date
• Shelter Check out date
• Personal Identification number
• Shelter Site Identification number

I acknowledge that per the Emergency Non-Congregate Sheltering Memo issued on 6/28/2022, Applicants must provide the method used to determine a
household’s habitability status and provide that information to FEMA. The Applicant can use either IA information, Home Assessment information, or a habitability
assessment process developed by the Applicant. The Applicant must submit the habitability determination method with all time extension requests. Additionally,
the Applicant should maintain information about the basic habitability of each individual and household in NCS during the period for which the Applicant is
requesting a time extension.
I certify that all information provided regarding the request for approval is true and correct to the best of my knowledge. Upon submittal the request for approval
becomes a legal document. The Recipient or FEMA may use external sources to verify the accuracy of the information I have entered. It is a violation of Federal
law to intentionally make false statements or hide information when applying for Public Assistance. This can carry severe criminal and civil penalties including a
fine of up to $250,000, imprisonment, or both. (18 U.S.C. §§ 287, 1001, 1040, and 3571). I understand that, if I intentionally make false statements or conceal any
information in an attempt to obtain Public Assistance, it is a violation of Federal laws, which carry severe criminal and civil penalties.

FEMA Form FF-104-FY-22-238 (11/23)

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