FF-104-FY-21-193 ( Direct Temporary Housing Assistance Recertification Work

Direct Housing Assistance Forms

FF-104-FY-21-193 (formerly 009-0-134)

OMB: 1660-0138

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DEPARTMENT 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

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

IF SO, HAS A CONTRACTOR BEEN HIRED OR VOLUNTEERED?

CONTRACTOR'S NAME:

PERMITS OBTAINED?

22b. HOUSING COSTS (RENTERS ONLY)
Pre-Disaster Rent:

DELAY IN COMPLETING THE REPAIRS TO THE DAMAGED
DWELLING?

CONTRACTOR'S PHONE #:
IF YES, PLEASE
SPECIFY:

DATE:

CONTRACTOR'S ADDRESS:

DELAY IN PURCHASING A HOME?

YES

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:

DID THE APPLICANT REFUSE THE RENTAL RESOURCE?

YES

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?

IF SO, PLEASE SPECIFY
THE VERIFIED
DOCUMENTATION:
PRE-DISASTER HUD/SECTION 8:

YES

STATE HOUSING/GRANT ASSISTANCE PROGRAM:

YES

VAL ASSISTANCE

YES

DRAFT

COMMENTS:
RENTAL RESOURCE #1:

RENTAL RESOURCE #2:

Address:

Contact's Name:

Type of Rental Resource:

Number of Bedrooms:

Monthly Rent:

RENTAL RESOURCE #3:

RENTAL RESOURCE #4:

Address:

Contact's Name:

Type of Rental Resource:

Number of Bedrooms:

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)

NUMBER OF MONTHS

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

Tub/Shower

Wall

Faucets/Plumbing

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

First 2 letters of
Applicant's last name

123456789

9 Digit FEMA
Registration ID#

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

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