#3 Generic Application- Release and Certification (Entity)

Request for Approval under the
“Generic Clearance for Notice of Loss and Proof of Loss”
(OMB Control Number: 1660-0159)

TITLE OF INFORMATION COLLECTION: FF-104-FY-22-253 Release and Certification
(Entity) – Partial Payment (English) & FF-104-FY-22-253-A Release and Certification (Entity) –
Partial Payment (Spanish)
PURPOSE: Use of FEMA Form FF-104-FY-22-253 Release and Certification Form (Entity)Partial Payment serves to expedite payments where it is appropriate, while informing the entity
that partial payment cannot be appealed, and acceptance of a partial payment does not affect the
claimant’s ability to pursue an appeal, arbitration, or other options under the Act. The
information requested includes Entity information (name, contact information including phone
number, current mailing and damaged property address and claim number); payment information
and identity verification (tax identification number, business identification number, or other form
of identification, DUNS number, bank institution, bank routing number, and bank account
number); final payment amount.

DESCRIPTION OF RESPONDENTS: The target group for this information collection comprises
individuals, households, and entities directly affected by a fire. These respondents include those
who have experienced the impact of fire on their homes, livelihoods, and over-all well-being.
The aim is to engage with those who have first-hand knowledge of the challenges, losses, and
needs resulting from a fire.

Key Characteristics of the Respondents:
1. Residential Impact: Individuals who have seen their homes directly impacted by the fire,
whether through damage, destruction, or evacuation.
2. Economic Impact: Households that may have experienced economic setbacks due to the fire,
including disruptions to employment, business operations, or income sources.
3. Community Engagement: Individuals actively involved in the affected community, fostering a
community-centric approach to understanding the collective impact and needs.
4. Varying Demographics: Respondents may represent diverse demographic profiles, including
age, income levels, family structures, and cultural backgrounds.
5. Multi-Household Dynamics: Understanding the dynamics of households, especially those with
varying family structures or shared living arrangements, to tailor assistance and support
accordingly.
6. Specific Needs: Identification of specific needs arising from the fire, such as immediate
housing, financial support, healthcare, or emotional well-being.
7. Geographic Location: Recognizing the geographical dispersion of impacted individuals and
households to ensure a comprehensive understanding of the varied challenges faced.
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TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[ ] Customer Satisfaction Survey
[ ] Small Discussion Group
[ ] Other: Claims Processing

CERTIFICATION:
I certify the following to be true:
1. The collection is required to obtain benefits.
2. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
3. FEMA needs to collect necessary information to perform these activities.
4. Usability testing has been completed on this instrument.
Digitally signed by TYLER C

Digital Signature:
To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ X ] Yes [ ] No
2. If Yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974? [ X ] Yes [ ] No
3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X ] No
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ X] No
BURDEN HOURS: The estimated annual burden hours to respondents is 7,181.25 hours.
Category of Respondent
Individuals/Households

No. of
Respondents
9,479

Participation
Time
.25

For-Profit Businesses and Not-for-Profit Institutions

18,959

.25

State, local, and Tribal Government
Totals

287

.25

FEDERAL COST: The estimated annual cost to the Federal government is $482,963.

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Burden
2,369.7
5
4,739.7
5
71.75
7,181.2
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If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents
1. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
[ ] Yes [ ] No
If the answer is yes, please provide a description of both below (or attach the sampling plan)? If
the answer is no, please provide a description of how you plan to identify your potential group of
respondents and how you will select them?
Response:

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ ] Web-based or other forms of social media
☒ Telephone
☒In-person
☒ Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [X] Yes [ ] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

Instructions for completing Request for Approval under the “Generic
Clearance for Notice of Loss and Proof of Loss”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g. Comment card for soliciting feedback on xxxx)
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include this in your explanation.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions.

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Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal
governments; or (4) Federal Government. Only one type of respondent can be selected.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses and the
participation time and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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