FEMA Form FF-104-F Smoke & Ash Cleaning

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

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

Hermit's Peak/Calf Canyon Claims Office

SMOKE & ASH CLEANING
CLAIMANT CONTACT INFORMATION
Claim Number:

Primary Claimant Name:

Damaged Property Address:
City, State, and Zip:
Coordinates (Optional):
Latitude:
Contact Phone Number:

DRAFT
Longitude:
Email (Optional):

Are you the legal owner of the damaged property or do you rent?
Own
Rent

Are there others with a legal interest in the property?
Yes
No

NAMES OF OTHER OWNERS

MAIN STRUCTURE

Estimated Sq. Ft. of dwelling (include attached garage):

Number of Stories:

CONTENTS

Are you requesting compensation for
contents cleaning?
Yes

Cleanup and Restoration Actions Taken (Describe any cleanup or restoration efforts
already undertaken for the affected areas):

No

OTHER STRUCTURES ON PROPERTY
Are there detached structures on the property for cleaning?
Yes
No
LIST OF DETACHED STRUCTURES
TYPE OF STRUCTURE

ESTIMATED SQ. FT.

NUMBER OF STORIES

Additional Information:

FEMA Form FF-104-FY-24-117 (3/24)

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CO-OWNERS
The undersigned declares under penalty of perjury under the laws of the United States that the foregoing is true and accurate. The
undersigned also declares under penalty of perjury under the laws of the United States that they are the legal owner of the property
that requires cleaning and that all legal owners are identified:
Primary Claimant Signature:

Claimant Printed Name:

Date:

If the property has additional legal co-owners, they should sign below and indicate their payment preferences.
The undersigned declares under penalty of perjury under the laws of the United States that the information documented about the
reported structures, contents, and need for smoke, ash, and soot cleaning on this worksheet is true and correct. The undersigned
also declares under penalty of perjury under the laws of the United States that they are a legal owner of the property that requires
cleaning and that all other legal owners are identified and have also signed.

DRAFT

Do all co-owners consent to a single payment made to the above primary claimant?
Yes
No

If "No" to question above, all co-owners should identify the percentage of payment they should each receive next to their name
(including the primary claimant listed above):
Co-Owner Signature:

Co-Owner Printed Name:

% of Payment: Date:

Co-Owner Signature:

Co-Owner Printed Name:

% of Payment: Date:

Co-Owner Signature:

Co-Owner Printed Name:

% of Payment: Date:

FEMA Form FF-104-FY-24-117 (3/24)

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