Form FEMA Form FF-104-F FEMA Form FF-104-F Evacuation Information Worksheet

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. XXX-XXX
Expiration Date: XX/XX/XXXX

Hermit's Peak/Calf Canyon Claims Office

EVACUATION INFORMATION WORKSHEET
CLAIMANT CONTACT INFORMATION
Claim Number:

Primary Claimant Name:

Age:

Current Address:
City, State, Zip, and County:
Contact Phone Number:

Email (Optional):

DRAFT
OTHER FAMILY MEMBERS

#
1
2
3

NAME

AGE

Evacuation Destination:
Dates of Evacuation:

Total Miles for Reimbursement Request:
Evacuation Lodging Type:

Total Lodging Expenses:
$
Additional Expenses (Please provide explanation of additional expenses below):
$

Did you experience food loss?
Yes
No

Could you return home after evacuation?
Yes
No

Additional Information:

The undersigned declares under penalty of perjury under the laws of the United States that the information provided is true and
accurate.
Claimant Signature:

FEMA Form FF-104-FY-24-114 (3/24)

Claimant Printed Name:

Date:

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