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pdfDEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
DIRECT TEMPORARY HOUSING ASSISTANCE RECERTIFICATION WORKSHEET
OMB No.: 1660-0138
Expiration Date: XX-XX-XXXX
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 20 minutes per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form.
This collection of information is mandatory. You are not required to respond to this collection of information unless a valid OMB control number
appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing
this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C
Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0138). Please do not send your completed survey to the above
address.
PRIVACY ACT STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part
206.117.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining the continued eligibility for occupants of
direct temporary housing assistance under a Presidentially-declared disaster.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974,
as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster
Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by
law.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent the applicant from receiving the requested disaster-related temporary housing assistance.
1. DISASTER #:
DRAFT
2. APPLICANT NAME:
4. PRE-DISASTER HOUSING STATUS: 5. ADDRESS OF TEMPORARY HOUSING UNIT (THU):
OWNER
RENTER
7. PARK/SITE NAME:
6. # OF BEDROOMS IN UNIT THU:
1
2
3
8. CURRENT PHONE #:
9. MOVE-IN DATE:
9a. TARGET MOVE-OUT DATE:
12. SITE TYPE:
Private Site
Other
3. REGISTRATION #:
10. LOT #:
11. SITE CONTROL #:
13. RECERTIFICATION DATE:
14. TRANSPORTABLE TEMPORARY
HOUSING UNIT (TTHU) INFORMATION:
Group Site
Commercial Park
Multi-Family Lease
and Repair
Direct Lease
15. VIN # (Applicable to MHU): 16. BARCODE # (Applicable to MHU): 17. RECERTIFICATION VISIT #: 17a. DATE OF LAST RECERTIFICATION
VISIT:
AUTH
18. Persons Living in THU:
NAME
REL
SEX AGE YES NO
FEMA FORM FF-104-FY-21-193 (formerly 009-0-134)
(12/21)
19. Household Income of all Occupants 18 Years of Age or Older
a. PRE-DISASTER INCOME
Initials
b. POST-DISASTER INCOME
Initials
Page 1 of 6
21. FMR FOR COUNTY/JURISDICTION OF DAMAGED DWELLING:
20. BEDROOM REQUIREMENT:
22. HOUSING COSTS (OWNERS ONLY)
*Pre-Disaster Mortgage:
*Post-Disaster Mortgage:
Pre-Disaster Utilities:
Post-Disaster Utilities:
*Includes Mortgage, Property Taxes, Homeowners insurance
22a. HOUSING PLAN PROGRESS FOR OWNERS
HAVE THE REPAIRS BEGUN?
YES
NO
IF SO, HAS A CONTRACTOR BEEN HIRED OR VOLUNTEERED?
CONTRACTOR'S NAME:
PERMITS OBTAINED?
22b. HOUSING COSTS (RENTERS ONLY)
Pre-Disaster Rent:
NO
DELAY IN COMPLETING THE REPAIRS TO THE DAMAGED
DWELLING?
CONTRACTOR'S PHONE #:
IF YES, PLEASE
SPECIFY:
NO
DATE:
CONTRACTOR'S ADDRESS:
DELAY IN PURCHASING A HOME?
YES
YES
YES
NO
YES
NO
DRAFT
FEMA FORM FF-104-FY-21-193 (formerly 009-0-134)
(12/21)
PERCENTAGE OF
REPAIRS COMPLETE:
Pre-Disaster Utilities:
Page 2 of 6
DIRECT TEMPORARY HOUSING ASSISTANCE RECERTIFICATION WORKSHEET
22c. HOUSING PLAN PROGRESS FOR RENTERS
RENTAL RESOURCES OFFERED
YES
NUMBER OF RENTAL RESOURCES OFFERED:
NO
DID THE APPLICANT REFUSE THE RENTAL RESOURCE?
YES
NO
IF YES, PLEASE SPECIFY
THE REFUSAL REASON:
23. REALISTIC PERMANENT HOUSING PLAN
RENT A RENTAL RESOURCE
REPAIR/REBUILD DAMAGED DWELLING
MOVE IN WITH FAMILY/FRIENDS
23a. PROJECTED DATE FOR
HOUSING PLAN COMPLETION
PURCHASE A HOME
PURCHASE FEMA TTHU (APPLICABLE IF
SALES TO OCCUPANTS IS ACTIVATED)
YES
23b. PERMANENT HOUSING PLAN DOCUMENTATION VERIFIED?
NO
IF SO, PLEASE SPECIFY
THE VERIFIED
DOCUMENTATION:
PRE-DISASTER HUD/SECTION 8:
YES
NO
STATE HOUSING/GRANT ASSISTANCE PROGRAM:
YES
NO
VAL ASSISTANCE
YES
NO
DRAFT
COMMENTS:
RENTAL RESOURCE #1:
RENTAL RESOURCE #2:
Address:
Address:
Contact's Name:
Contact's Name:
Type of Rental Resource:
Type of Rental Resource:
Number of Bedrooms:
Number of Bedrooms:
Monthly Rent:
Monthly Rent:
RENTAL RESOURCE #3:
RENTAL RESOURCE #4:
Address:
Address:
Contact's Name:
Contact's Name:
Type of Rental Resource:
Type of Rental Resource:
Number of Bedrooms:
Number of Bedrooms:
Monthly Rent:
Monthly Rent:
24. FEMA RECERTIFICATION ADVISOR NAME:
24a. RECERTIFICATION RECOMMENDATIONS:
25. HOUSING GROUP SUPERVISOR SIGNATURE
APPROVED CONTINUED
APPROVED DATES
DENIED
FROM
25a. DENIAL REASONS:
DATE
TOTAL MONTHS:
TO
GENERAL VIOLATION
MAJOR VIOLATION
OTHER (See Notes)
NOTES:
26. FOR SUPERVISOR USE ONLY
RECERTIFICATION APPROVED?
YES
FEMA FORM FF-104-FY-21-193 (formerly 009-0-134)
(12/21)
NO
NUMBER OF MONTHS
1
2
3
Page 3 of 6
DIRECT TEMPORARY HOUSING ASSISTANCE RECERTIFICATION CHECKLIST
Applicant's Name:
Disaster #:
Registration #:
INTRODUCTION
Introduce yourself and show the person your FEMA Identification.
Explain why you are there - to conduct a recertification.
Verify the identity of the person completing the recertification (applicant or co-applicant).
Verify Written Consent/Release of Information on file (ROI).
Verify the unit number (Applicable to MHU).
Provide a scope of the Recertification.
Explain what you will be doing today.
RECERTIFICATION WORKSHEET
Complete Worksheet.
If a copy of income and mortgage information is not provided by applicant, take picture of the original document.
Document the housing plan information provided during each recertification visit i.e. lease, housing searches, progress of repairs
to damaged dwelling address.
DRAFT
Verify Written Consent/Release of Information on file (ROI).
Make appropriate contacts to contractors to confirm progress of repairs. Make contacts to rental resources to confirm availability.
Offer rental resources when appropriate.
Conduct a follow-up with the applicant to ensure rental resources provided were contacted.
REPAIR PROGRESS CHECKLIST (OWNERS ONLY)
Inform occupant of the need to evaluate what repairs have been completed.
Document and evaluate the repairs and damage to the dwelling which has rendered the home inhabitable (essential repairs only).
If necessary, go to damaged dwelling and record outside condition (e.g., does it look like repair work has begun). Record the
observations in comments section.
If unsure about the state of repairs, ask the occupant if it was damaged or has already been repaired.
Explain to occupant that you are only recording what you observe.
Contact contractor on the progress and completion of the repairs to the pre-disaster damaged dwelling. Confirm any delays on the
progress and completion of the repairs (if applicable).
Complete Checklist.
PICTURE PROTOCOL
Take a picture of every damaged room (First Recert Only).
Take a picture of each room that is still being repaired. Picture should capture the damage to that specific room.
Take a picture of the exterior damages that are still in the repair phase; essential to the habitability of the dwelling.
RECAP
Document the condition (e.g., maintenance issues, interior, exterior damages and furnishings) of the unit on the Transportable
Temporary Housing Unit Inspection Report (FF-104-FY-21-111).
Document the occupant's NEMIS file with all recertification information documented as each visit.
Inform the occupant of your recommendation for recertification and what was observed during this visit.
Inform the occupant they will be notified within 7 - 14 days of their eligibility for recertification.
Provide FEMA Contact Numbers (Helpline, Maintenance, Sales, etc.).
Remind occupant to update FEMA if contact information changes, e.g., phone number.
FEMA FORM FF-104-FY-21-193 (formerly 009-0-134)
(12/21)
Page 4 of 6
REPAIR PROGRESS CHECKLIST (FOR PRE-DISASTER OWNERS ONLY)
2. RECERTIFICATION #:
3. PRIMARY OCCUPANT'S NAME:
4. REGISTRATION ID #:
1. INSPECTION DATE:
5. DISASTER #:
7. DAMAGED DWELLING DESCRIPTION:
6. DAMAGED DWELLING ADDRESS:
Apartment
House-Single/Duplex
Boat
Mobile Home
Condo
Townhouse
8. CONDITION OF ROOMS, INTERIOR, & EXTERIOR AT THE TIME OF RECERTIFICATION
Instructions: Take basic pictures of essential rooms and damages that continue to render the home unlivable.
RP=Repairs Completed RB=Repairs Begun RN=Repairs Not Started UD=Undamaged N/A=Non Applicable
Picture
Picture
Damages
Taken Condition
Room
Taken Condition
Room
Living Room (LR)
Bedroom 1 (BR1)
Bathroom 1 (BA1)
Ceiling
Ceiling
Toilet
Floor
Floor
Sink
Outlet/Switches
Outlet/Switches
Tub/Shower
Wall
Wall
Faucets/Plumbing
Window
Window
Walls
Bedroom 2 (BR2)
Window
Ceiling
Cabinet
Floor
Bathroom 2 (BA2)
Outlet/Switches
Toilet
Wall
Sink
Kitchen (KIT)
Cabinets
Ceiling
Faucets/Plumbing
Floor
Outlet/Switches
Picture
Taken Condition
DRAFT
Window
Tub/Shower
Range
Bedroom 3 (BR3)
Faucets/Plumbing
Refrigerator
Ceiling
Walls
Sink
Floor
Window
Wall
Outlet/Switches
Cabinet
Window
Wall
Bathroom 3 (BA3)
Utilities
Window
Toilet
Furnace
Bedroom 4 (BR4)
Sink
HVAC
Ceiling
Tub/Shower
Water Heater
Floor
Faucets/Plumbing
Utilities
Outlet/Switches
Walls
Gas
Wall
Window
Electric
Window
Cabinet
Water
Exterior Walls
Hallway (HWY)
EWL
Other (OTH)
Debris that hinders
repairs or access to DD
Walls
Outlet/Switches
Travel Trailer
Other
EWR
EWF
Utility Connections
(septic, water, electric)
EWB
Wall Framing
9a. COMMENTS
PLACED IN NEMIS?
YES
NO
9. COMMENTS
10. NAME OF PERSON PRESENT DURING RECERTIFICATION: 11. RELATIONSHIP TO PRIMARY OCCUPANT(i.e. Authorized Household Mbr, Occupant):
12. FEMA RECERTIFICATION ADVISOR NAME:
FEMA FORM FF-104-FY-21-193 (formerly 009-0-134)
(12/21)
13. FEMA RECERTIFICATION STAFF SIGNATURE:
14. DATE:
Page 5 of 6
CONTINUED ASSISTANCE
PICTURE NAMING CONVENTION
ME
-
First 2 letters of
Applicant's last name
123456789
9 Digit FEMA
Registration ID#
-
LR
-
080309
Room
Identifier
Date
MM/DD/YY
Room Identifier Legend
EXTERIOR
INTERIOR ANCILLARY SPACE
EWB: Exterior Wall Back
EWF: Exterior Wall Front
EWL: Exterior Wall Left
EWR: Exterior Wall Right
CRL: Crawlspace
BSM: Basement
FR: Family Room
HWY: Hallway
OTH: Other
UTM: Utility Room
INTERIOR LIVING SPACE
BA1: Bathrooms (Numbering from closet or inside the master
bathroom to furthest away)
BR1: Bedrooms (Numbered from closet to master bedroom to
furthest away)
DR: Dining Room
KIT: Kitchen
LR: Living Room
DRAFT
WH
-
First 2 letters of
Applicant's last name
123456789
9 Digit FEMA
Registration ID#
- PSB -
Document
Identifier
050109
Date
MM/DD/YY
Document Identifier Legend
INCOME
PSB: Pay Stub
SSA: Social Security Statements
IST: Investment Statements (ex. Stocks, Mutual
Funds, Money Market Accounts)
UES: Unemployment Benefits Statement
RBS: Retirement Benefits Statement
OTR: Other Income Documents (ex. Bank
Statements, Deposit Slips, etc.)
FEMA FORM FF-104-FY-21-193 (formerly 009-0-134)
(12/21)
CURRENT HOUSING COSTS
MS 1-2: 1st and 2nd Mortgage Statement
PTR: Property Tax Receipt
HOI: Homeowners Insurance Statement or Declaration Page
GRT: Ground Rent
NOTE: Any Income and Current Housing Cost documentation will have
sensitive Personally Identifiable Information (PII) such as Social Security
numbers or Account Numbers. This Information MUST be covered to
protect Privacy and Identity.
Page 6 of 6
| File Type | application/pdf |
| File Title | FEMA Form |
| File Modified | 2021-12-22 |
| File Created | 2015-07-10 |