FEMA Form FF-104-F Evacuee Hosting

DEPARTMENT OF HOMELAND SECURITY

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

Federal Emergency Management Agency
Hermit's Peak/Calf Canyon Claims Office

EVACUEE HOSTING
CLAIMANT CONTACT INFORMATION
Claim Number:

Primary Claimant Name:

Current Address:
Contact Phone Number:

Email (Optional):

EVACUEES HOSTED (If additional space is needed, please use the additional information box below)
NAME

AGE

GENDER

DRAFT

Dates of Hosting:

**Note: You are only required to submit amounts for utility expenses, food expenses, and total compensation if requesting
reimbursement for actual cost. If using the Claims Office standard rate, these amounts will be estimated after submission of this form.**
Total Utility Expenses:
Total Food Expenses:
Claimed Increase Mileage:
$
$
Additional Expenses (Please provide explanation of additional expenses below):
$

Total Host Compensation:
$
Additional Information:

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

FEMA Form FF-104-FY-24-115 (3/24)

Claimant Printed Name:

Date:

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