FEMA Form FF-104-F #2 Release and Certification (Individual/Household)- Par

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1600-0159
Expiration Date: XX/XX/20XX

Hermit's Peak/Calf Canyon Claims Office

RELEASE AND CERTIFICATION (INDIVIDUAL/HOUSEHOLD) – PARTIAL PAYMENT
I, the undersigned, filed a claim pursuant to the Hermit's Peak/Calf Canyon Fire Assistance Act, Pub. L. No. 117-180, 136 Stat. 2114
(the “Act”) for damages resulting from the Hermit's Peak/Calf Canyon Fire (the “Fire”) with the Hermit's Peak/Calf Canyon Claims Office
(the “Claims Office”). Pursuant to Section 104(d)(2) of the Act and after investigation, the Office determined that I suffered a partial
compensable loss on a severable portion of my claim in the amount of $
for my loss as set forth in the Proof of Loss,
I acknowledge that, to the extent that the partial payment represents compensation for actual costs, a partial payment in the amount
set forth above fully satisfies all my outstanding claims against the Federal Emergency Management Agency and/or the United
States for any damage related to the severable portion of my loss. I agree that the payment is final and conclusive with respect to
the severable portion of my injuries that are calculated based on actual costs, and that by accepting partial payment for actual costs
in the amount referenced above, I am completely and forever releasing the Federal Emergency Management Agency and the United
States from any past, present, and future claims related to that severable portion of my loss. To the extent the partial payment is
based on an estimated amount of damages for the loss, if actual costs to repair or replace structures or infrastructure damaged by
the Fire and cascading impacts, exceed the amount of the estimated partial payment, I understand that I may include the excess
amount in my final Proof of Loss or request to reopen my claim as provided by law.

DRAFT

I understand that by signing this Release and Certification - Partial Payment I reserve the right to continue to pursue other claims
under the Act not related to the severable losses identified on the Proof of Loss. I further understand that the decision to provide a
partial payment cannot be appealed, but acceptance of a partial payment does not affect my ability to pursue an appeal, arbitration,
or other options under the Act with respect to any portion of a claim for which a Release and Certification Form is not executed.
This Release and Certification constitutes the complete agreement of the parties and may only be amended by the written
agreement of both myself and the Federal Emergency Management Agency.
I,

, under penalty of law, hereby proclaim that I am fully authorized to act on behalf of the

Claimant regarding all past, present, and future claims relating to the Hermit’s Peak/Calf Canyon Fire Assistance Act. I understand
that civil and/or criminal penalties may arise pursuant to the False Claims Act, 31 U.S.C. § 3729, et seq., and/or other applicable law
for any fraudulent statements or representations made in this regard.
Being a duly authorized and recognized representative and/or agent of the Claimant, I agree on behalf of the Claimant to the terms
and acknowledgments contained in this agreement.
I declare under penalty of perjury that the information I have provided regarding claimant’s loss is true and correct.

**Note: All individuals who have an ownership in the items being paid under this POL are required to sign this document..**
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Printed Name:
SSN or TIN:

Date Signed:
Claim Number:

Phone Number:

Email Address (Optional):

FEMA Form FF-104-FY-22-252 (12/23)

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