Form FEMA Form FF-104-F FEMA Form FF-104-F #1 Proof of Loss (English)

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-0159
Expiration Date: XX/XX/20XX

Hermit's Peak/Calf Canyon Claims Office

PROOF OF LOSS
CLAIMANT CONTACT INFORMATION
Name:
Current Address:
City, State, Zip:
Damaged Property Address:
City, State, Zip:
Phone Number:

Fax No.:

E-mail Address:

Claim Number:

For verification purposes, please provide one or more of the following:
Tax Identification Number

DRAFT

Business Identification Number

Other form of identification (Driver's license, Student ID, etc.)

Compensation under the Hermit’s Peak/Calf Canyon Fire Assistance Act is available to all injured persons, regardless of the
citizenship or alien status of the individual.

TYPE OF PROOF OF LOSS

Partial Payment Proof of Loss

Final Proof of Loss

What type of claim does this Proof of Loss cover? (Check only one option)
Individual or Household

Not-for-Profit

Business

Government

Tribal Nation/Tribal Government

Other:

and is submitted
This Proof of Loss relates to the Notice of Loss acknowledged by the Claims Office on
pursuant to the Hermit's Peak/Calf Canyon Fire Assistance Act for injuries resulting from the Hermit’s Peak/Calf Canyon Fire.

AMOUNTS CLAIMED
The following are the amounts claimed, by category, by the Claimant:
Medical Expenses
Medical Expenses
Lost Personal Income
Real Property

$
$

Address:

Repair
Replacement
Decreased Value
Reforestation and/or Revegetation
Debris Removal and Other Clean-Up Costs
NRCS Plan Estimates
Decreased Value

$
$
$
$
$
$
$

Personal Property
Vehicles/Equipment
Contents
Other

FEMA Form FF-104-FY-22-231 (12/23)

$
$
$

Page 1 of 4

Flood Insurance
Flood Policy Reimbursement
NFIP Policy Request

$
$

Insurance Deductible
Homeowner Insurance
Vehicle Insurance
Personal Property Insurance
Flood Insurance

$
$
$
$

Evacuation/Relocation
Evacuation Expenses
Temporary Housing/Relocation Expenses
Moving and Storage Expenses

$
$
$

SBA Loan Repayment

$

Business Interruption Expenses

$

Risk Reduction

DRAFT

Individual Household Risk Reduction
Community Scale Risk Reduction

$
$

Other (Brief Description)
Total Amount Claimed

$

Write a statement describing the nature and extent of each injury for which you are requesting compensation. If you have any
questions about the information to include with this Proof of Loss, please coordinate with your Navigator. Ensure that you write your
name and claim number on all documents submitted with this form. If you are working with a Navigator, you may state that you have
provided this documentation to them. Additionally, retain copies of all original documents and keep a copy of this Proof of Loss form
for your records.

YOU MUST SIGN THE CERTIFICATION ON PAGE 3 BEFORE SUBMITTING THIS PROOF OF LOSS

FEMA Form FF-104-FY-22-231 (12/23)

Page 2 of 4

CERTIFICATION
This Proof of Loss consists of this form and the attached or previously submitted documents supporting the claim(s). The
undersigned Claimant (or legal representative of the Claimant if a business or individual) declares under penalty of perjury under the
laws of the United States that all the information on this form is true and correct. The undersigned Claimant (or legal representative
of the Claimant if a business or individual) further certifies under penalty of perjury that no amount claimed in this Proof of Loss has
been paid or will be paid by insurance, other assistance programs, or any other source.
Individual and Household Claimants Sign Below:
1. Name of Claimant:

Claimant Signature

Date

2. Name of Claimant:

Claimant Signature

DRAFT
Date

3. Name of Claimant:

Claimant Signature

Date

4. Name of Claimant:

Claimant Signature

Date

5. Name of Claimant:

Claimant Signature

Date

6. Name of Claimant:

Claimant Signature

Date

7. Name of Claimant:

Date

Claimant Signature

Please include additional signatures on another page if needed.

FEMA Form FF-104-FY-22-231 (12/23)

Page 3 of 4

PRIVACY ACT NOTICE
This Notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a(e)(3), and concerns the information requested in the Notice of Loss form to
which this Notice is attached. The authority for the collection of this information is Hermit’s Peak/Calf Canyon Fire Assistance Act, Public Law
117-180. The information you provide will be used to verify your identity, to verify your eligibility, and to verify any previous compensation made in
connection with the Hermit’s Peak/Calf Canyon Fire. Some or all of the information you provide may be released to federal, state, and local
government agencies or private organizations for the purpose of confirming your identity, your eligibility and any previous compensation or payments
made in connection with the Hermit’s Peak/Calf Canyon Fire. The information may also be released when otherwise authorized by statute or
regulation. Disclosure of the information by you is required in order for you to make a claim under the Act. It will not be possible to process your claim
without the information.
Routine Uses: The Privacy Act permits us to disclose information about individuals without their consent for a routine use, i.e., when the information
will be used for a purpose that is compatible with the purpose for which we collected the information. The routine uses of this system are:
a) Disclosure may be made to agency contractors who have been engaged to assist the agency in the performance of a contract service related
to this system of records and who need to have access to the records in order to perform the activity. Recipients shall be required to comply
with the requirements of the Privacy Act of 1974, as amended, 5 U.S.C.552a.
b) Disclosure may be made to a member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office
made at the written request of the constituent about whom the record is maintained.
c) Disclosure may be made to other Federal agencies who provided assistance to claimants related to the Hermit's Peak/Calf Canyon Fire, in
order to ensure that benefits are not duplicated.

DRAFT

d) Disclosure of information submitted by an individual claimant may be made to an insurance company or other third party which has submitted
a subrogation claim relating to such claimant when it is necessary in FEMA’s opinion to ensure that benefits are not duplicated and to
efficiently coordinate the processing of claims brought by individuals and subrogees.
e) When a record, either independently or in conjunction with other records, suggests a violation or potential violation of the law--whether civil,
criminal, or regulatory in nature, and whether arising under general statute, a particular program statute, or through a regulation, rule, or order
issued pursuant thereto--disclosure may occur to the appropriate agency. This agency may be Federal, foreign, state, local, or another public
authority responsible for enforcing, investigating, or prosecuting the violation. Additionally, disclosure may extend to entities charged with
enforcing or implementing the relevant statute, rule, regulation, or order. The disclosed information is relevant to the enforcement, regulatory,
investigative, or prospective responsibilities of the receiving entity.
f) Disclosure may be made to the National Archives and Records Administration for the purpose of conducting records management studies
under the authority of 44 U.S.C. 2904 and 2906.
Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply the requested information or to execute the form may render your
claim “invalid.”

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 45 minutes per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You
are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding
the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street. SW, Washington, DC 20472-3100, Paperwork Reduction Project
(1660-0155) NOTE: Do not send your completed form to this address.

FEMA Form FF-104-FY-22-231 (12/23)

Page 4 of 4