Generic Clearance for Notice of Loss and Proof of Loss

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FEMA Form FF-104-F Banking Information Form (Entity) Spanish	Form	New	Repair queued
Form FEMA Form FF-104-F Banking Information Form (Entity)	Form	New	Repair queued
Form FEMA Form FF-104-F Notice of Request for Arbitration Form (Spanish)	Form	New	Repair queued
Form FF-104-FY-25-100 Notice of Request for Arbitration Form (English)	Form	New	Repair queued
Form FF-104-FY-24-117-E Smoke & Ash Cleaning Form (Spanish Version)	Form	New	Repair queued
Form FF-104-FY-24-121-E Risk Reduction Proposal Form (Spanish Version)	Form	New	Repair queued
Form FF-104-FY-24-122-E Notice of Appeal (Spanish Version)	Form	New	Repair queued
Form FF-104-FY-24-116-A Flood Insurance Assessment (Spanish Version)	Form	New	Repair queued
Form FF-104-FY-24-115-E Evacuee Hosting (Spanish Version)	Form	New	Repair queued
Form FF-104-FY-24-114-E Evacuation Information Worksheet (Spanish Version)	Form	New	Repair queued
Form FEMA Form FF-104-F Proof of Loss (Spanish)	Form	New	Repair queued
Form FEMA Form FF-104-F Release and Certifications (Individuals and Households) - Partial Payment (Spanish)	Form	New	Repair queued
Form FEMA Form FF-104-F Release and Certifications (Entity) - Partial Payment (Spanish)	Form	New	Repair queued
Form Form FF-104-FY-22- Notice of Loss (Spanish)	Form	New	Repair queued
Form FEMA Form FF-104-F Banking Information Form (Spanish)	Form	New	Repair queued
Form FF-104-FY-24-122 Notice of Appeal Request Form	Form	New	Repair queued
Form FEMA Form FF-104-F Risk Reduction Proposal	Form	New	Available
Form FEMA Form FF-104-F Smoke & Ash Cleaning	Form	New	Available
Form FEMA Form FF-104-F Flood Insurance Assessment	Form	New	Available
Form FEMA Form FF-104-F Evacuee Hosting	Form	New	Available
Form FEMA Form FF-104-F Evacuation Information Worksheet	Form	New	Available
Form FEMA Form FF-104-F Release and Certification (Entity) - Partial Payment	Form	New	Available
Form FEMA Form FF-104-F Release and Certification (Individual/Household) - Partial	Form	New	Available
Form FEMA Form FF-104-F Formulario de Informacion Bancaria	Form	New	Available
Form FEMA Form FF-104-F Banking Information Form	Form	New	Available
Form FEMA Form FF-104-F Comprobante de Perdida - Incendio en Hermit's Peak/Calf Canyon	Form	New	Available
Form FEMA Form FF-104-F Proof of Loss	Form	New	Available
Form FEMA Form FF-104-F Formulario de Notificacion de Perdida	Form	New	Available
Form FEMA Form FF-104-F Notice of Loss	Form	New	Available
Form FEMA Form FF-104-F Banking Information Form (Spanish)	Form	Unchanged	Available
Form FEMA Form FF-104-F Banking Information Form (English)	Form	Unchanged	Available
Form FEMA Form FF-104-F #5 Request to Supplement Claim (Spanish)	Form	Unchanged	Available
Form FEMA Form FF-104-F #5 Request to Supplement Claim (English)	Form	Unchanged	Available
Form FEMA Form FF-104-F #4 Notice of Loss (Spanish)	Form	Unchanged	Available
Form FEMA Form FF-104-F #4 Notice of Loss (English)	Form	Unchanged	Available
Form FEMA Form FF-104-F #3 Release and Certification (Entity)- Partial Payment (Spanish)	Form	Unchanged	Repair queued
Form FEMA Form FF-104-F #3 Release and Certification (Entity)- Partial Payment (English)	Form	Unchanged	Available
Form FEMA Form FF-104-F #2 Release and Certification (Individual/Household)- Partial Payment (Spanish)	Form	Unchanged	Repair queued
Form FEMA Form FF-104-F #2 Release and Certification (Individual/Household)- Partial Payment (English)	Form	Unchanged	Available
Form FEMA Forn FF-104-F #1 Proof of Loss (Spanish)	Form	Unchanged	Available
Form FEMA Form FF-104-F #1 Proof of Loss (English)	Form	Unchanged	Available
1660-0159 - Supporting Statement A - 2024 03 29.docx	Supporting Statement A	Uploaded 2024-03-29	Available
1660-0159 Signed Change Request - 2024 03 27.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2024-03-27	Available
1660-NW163 - Published 30-Day New Generic FRN - 2023 08 11.pdf	Supplementary Document	Uploaded 2023-08-11	Available
1660-NW163 - Published 60-Day New Generic FRN - 2023 05 05.pdf	Supplementary Document	Uploaded 2023-05-12	Available
PLAW-117publ103.pdf	Supplementary Document	Uploaded 2023-05-12	Available
USCODE-2021-title42-chap68.pdf	Supplementary Document	Uploaded 2023-05-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
277835	8th Batch of Hermit's Peak Instruments (New)	Form	New	Banking Information Form (Entity) Spanish
277835	8th Batch of Hermit's Peak Instruments (New)	Form	New	Banking Information Form (Entity)
272641	7th Batch of Hermit's Peak Instruments (New)	Form	New	Notice of Request for Arbitration Form (Spanish)
272641	7th Batch of Hermit's Peak Instruments (New)	Form	New	Notice of Request for Arbitration Form (English)
271165	6th Batch of Hermit's Peak Instruments (New)	Form	New	Smoke & Ash Cleaning Form (Spanish Version)
271165	6th Batch of Hermit's Peak Instruments (New)	Form	New	Risk Reduction Proposal Form (Spanish Version)
271165	6th Batch of Hermit's Peak Instruments (New)	Form	New	Notice of Appeal (Spanish Version)
271165	6th Batch of Hermit's Peak Instruments (New)	Form	New	Flood Insurance Assessment (Spanish Version)
271165	6th Batch of Hermit's Peak Instruments (New)	Form	New	Evacuee Hosting (Spanish Version)
271165	6th Batch of Hermit's Peak Instruments (New)	Form	New	Evacuation Information Worksheet (Spanish Version)
271130	5th Batch of Hermit's Peak Instruments (Revised)	Form	New	Proof of Loss (Spanish)
271130	5th Batch of Hermit's Peak Instruments (Revised)	Form	New	Release and Certifications (Individuals and Households) - Partial Payment (Spanish)
271130	5th Batch of Hermit's Peak Instruments (Revised)	Form	New	Release and Certifications (Entity) - Partial Payment (Spanish)
271130	5th Batch of Hermit's Peak Instruments (Revised)	Form	New	Notice of Loss (Spanish)
271130	5th Batch of Hermit's Peak Instruments (Revised)	Form	New	Banking Information Form (Spanish)
268525	4th Batch of Hermit's Peak Instrument (New)	Form	New	Notice of Appeal Request Form
266618	Third Batch of Hermits Peak Instruments (New)	Form	New	Risk Reduction Proposal
266618	Third Batch of Hermits Peak Instruments (New)	Form	New	Smoke & Ash Cleaning
266618	Third Batch of Hermits Peak Instruments (New)	Form	New	Flood Insurance Assessment
266618	Third Batch of Hermits Peak Instruments (New)	Form	New	Evacuee Hosting
266618	Third Batch of Hermits Peak Instruments (New)	Form	New	Evacuation Information Worksheet
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Release and Certification (Entity) - Partial Payment
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Release and Certification (Individual/Household) - Partial
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Formulario de Informacion Bancaria
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Banking Information Form
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Comprobante de Perdida - Incendio en Hermit's Peak/Calf Canyon
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Proof of Loss
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Formulario de Notificacion de Perdida
266617	Second Batch of Hermits Peak Instruments (Revised)	Form	New	Notice of Loss
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	Banking Information Form (Spanish)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	Banking Information Form (English)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#5 Request to Supplement Claim (Spanish)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#5 Request to Supplement Claim (English)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#4 Notice of Loss (Spanish)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#4 Notice of Loss (English)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#3 Release and Certification (Entity)- Partial Payment (Spanish)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#3 Release and Certification (Entity)- Partial Payment (English)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#2 Release and Certification (Individual/Household)- Partial Payment (Spanish)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#2 Release and Certification (Individual/Household)- Partial Payment (English)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#1 Proof of Loss (Spanish)
264452	Generic Clearance for Notice of Loss and Proof of Loss	Form	Unchanged	#1 Proof of Loss (English)

ICR Details

OMB Control No: 1660-0159	ICR Reference No: 202404-1660-002
Status: Active	Previous ICR Reference No: 202403-1660-006
Agency/Subagency: DHS/FEMA	Agency Tracking No: Change Request
Title: Generic Clearance for Notice of Loss and Proof of Loss
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/05/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/05/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2026	11/30/2026	11/30/2026
Responses	1,149,000	0	1,149,000
Time Burden (Hours)	2,929,962	0	1,149,000
Cost Burden (Dollars)	0	0	126,427,860

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Abstract: The Federal Emergency Management Agency (FEMA) will use the collected information to commence the process and procedures for claimants to seek compensation for injury or loss of property resulting from the Hermit’s Peak/Calf Canyon Fire and other fires that meet the criteria. Affected state, local and Tribal governments, private sector businesses, not-for-profit organizations, and individuals and households that suffered injuries resulting from fires will be eligible to apply for compensation. Claimants will submit a Notice of Loss to the Agency, meet with a FEMA Claims Reviewer, obtain documentation needed to substantiate claims, sign a Proof of Loss, and complete and return a Release and Certification form.

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Authorizing Statute(s): PL: Pub.L. 117 - 180 Division G Name of Law: Hermit's Peak/Calf Canyon Fire Assistance Act
   US Code: 42 USC 5121-5207 Name of Law: Stafford Act
  

Citations for New Statutory Requirements: PL: Pub.L. 117 - 180 Division G Name of Law: Hermit's Peak/Calf Canyon Fire Assistance Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 29144	05/05/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 54632	08/11/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
4th Batch of Hermit's Peak Instrument (New)	FF-104-FY-24-122	Notice of Appeal Request Form
5th Batch of Hermit's Peak Instruments (Revised)	FEMA Form FF-104-FY-22-251-A, Form FF-104-FY-22-230-A, FEMA Form FF-104-FY-22-253-A, FEMA Form FF-104-FY-22-252-A, FEMA Form FF-104-FY-22-231-A	Banking Information Form (Spanish) ,   Notice of Loss (Spanish) ,   Release and Certifications (Entity) - Partial Payment (Spanish) ,   Release and Certifications (Individuals and Households) - Partial Payment (Spanish) ,   Proof of Loss (Spanish)
6th Batch of Hermit's Peak Instruments (New)	FF-104-FY-24-122-ES, FF-104-FY-24-114-ES, FF-104-FY-24-115-ES , FF-104-FY-24-116-A, FF-104-FY-24-121-ES, FF-104-FY-24-117-ES	Evacuation Information Worksheet (Spanish Version) ,   Evacuee Hosting (Spanish Version) ,   Flood Insurance Assessment (Spanish Version) ,   Notice of Appeal (Spanish Version) ,   Risk Reduction Proposal Form (Spanish Version) ,   Smoke & Ash Cleaning Form (Spanish Version)
7th Batch of Hermit's Peak Instruments (New)	FF-104-FY-25-100 , FEMA Form FF-104-FY-25-100-A	Notice of Request for Arbitration Form (English) ,   Notice of Request for Arbitration Form (Spanish)
8th Batch of Hermit's Peak Instruments (New)	FEMA Form FF-104-FY-25-102-A, FEMA Form FF-104-FY-25-102	Banking Information Form (Entity) ,   Banking Information Form (Entity) Spanish
Generic Clearance for Notice of Loss and Proof of Loss	FEMA Form FF-104-FY-22-252-A, FEMA Forn FF-104-FY-22-231-A, FEMA Form FF-104-FY-22-231, FEMA Form FF-104-FY-22-253, FEMA Form FF-104-FY-22-253-A, FEMA Form FF-104-FY-22-230, FEMA Form FF-104-FY-22-230-A, FEMA Form FF-104-FY-22-254, FEMA Form FF-104-FY-22-252, FEMA Form FF-104-FY-22-254-A, FEMA Form FF-104-FY-22-251, FEMA Form FF-104-FY-22-251-A	#1 Proof of Loss (English) ,   #1 Proof of Loss (Spanish) ,   #2 Release and Certification (Individual/Household)- Partial Payment (English) ,   #2 Release and Certification (Individual/Household)- Partial Payment (Spanish) ,   #3 Release and Certification (Entity)- Partial Payment (English) ,   #3 Release and Certification (Entity)- Partial Payment (Spanish) ,   #4 Notice of Loss (English) ,   #4 Notice of Loss (Spanish) ,   #5 Request to Supplement Claim (English) ,   #5 Request to Supplement Claim (Spanish) ,   Banking Information Form (English) ,   Banking Information Form (Spanish)
Second Batch of Hermits Peak Instruments (Revised)	FEMA Form FF-104-FY-22-231-A, FEMA Form FF-104-FY-22-230-A, FEMA Form FF-104-FY-22-231, FEMA Form FF-104-FY-22-251, FEMA Form FF-104-FY-22-251-A, FEMA Form FF-104-FY-22-252, FEMA Form FF-104-FY-22-253, FEMA Form FF-104-FY-22-230	Notice of Loss ,   Formulario de Notificacion de Perdida ,   Proof of Loss ,   Comprobante de Perdida - Incendio en Hermit's Peak/Calf Canyon ,   Banking Information Form ,   Formulario de Informacion Bancaria ,   Release and Certification (Individual/Household) - Partial ,   Release and Certification (Entity) - Partial Payment
Third Batch of Hermits Peak Instruments (New)	FEMA Form FF-104-FY-24-114, FEMA Form FF-104-FY-24-115, FEMA Form FF-104-FY-24-116, FEMA Form FF-104-FY-24-117, FEMA Form FF-104-FY-24-121	Evacuation Information Worksheet ,   Evacuee Hosting ,   Flood Insurance Assessment ,   Smoke & Ash Cleaning ,   Risk Reduction Proposal

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,149,000	1,149,000	0	0	0	0
Annual Time Burden (Hours)	2,929,962	1,149,000	0	1,780,962	0	0
Annual Cost Burden (Dollars)	0	126,427,860	0	-126,427,860	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This increase is a technical correction to the previous change request workflow. The requested increase in burden hours now matches between the Change Request form and ROCIS.

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Annual Cost to Federal Government: $65,103,002

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/05/2024

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