Generic Application - Proof of Loss

Request for Approval under the

“Generic Clearance for Notice of Loss and Proof of Loss” (OMB Control Number: 1660-0159)

TITLE OF INFORMATION COLLECTION: FF-104-FY-22-231 Proof of Loss (POL)

(English) & FF-104-FY-22-231-A Proof of Loss (POL) (Spanish)

PURPOSE: Use of FEMA Form FF-104-FY-22-231 serves to further gather the specific details concerning the injuries sustained by Claimants to process the claim. Each item of information requested is needed to document and confirm the Claimant’s injuries. A Claims Reviewer will work directly with the Claimant to help Claimants better understand this form and how to complete it. The information requested includes Claimant information (name, contact information including phone number, email address, physical address and claim number); payment information and identity verification (social security number and/or tax identification number, business identification number, or other form of identification); type of claim (individual/household, business, government, Indian Tribe, non-profit, other); confirmation of the date the Claimant filed the Notice of Loss; amounts claimed by category by the Claimant on the claim for specific injuries for individuals/households (personal injury; real property; personal property; lost wages/personal income; increased mortgage costs; flood insurance premiums; insurance deductible; temporary living/relocation expenses; subsistence resources; other injuries); for businesses (real property; personal property/tangible assets/inventory; business interruption; overhead costs; emergency staffing expenses; employee wages for unperformed work; increased mortgage interest costs; flood insurance premiums; insurance deductible; temporary rental/relocation expense; other injuries); for government (real property; personal property/tangible assets/inventory; firefighting costs and emergency response; emergency staffing expenses; administrative expenses; temporary rental/relocation expenses; Tribal subsistence resources; other injuries); and the total amount of injuries/damages claimed

DESCRIPTION OF RESPONDENTS: The target group for this information collection comprises individuals, households, and entities directly affected by a fire. These respondents include those who have experienced the impact of fire on their homes, livelihoods, and over-all well-being. The aim is to engage with those who have first-hand knowledge of the challenges, losses, and needs resulting from a fire.

Key Characteristics of the Respondents:

1. Residential Impact: Individuals who have seen their homes directly impacted by the fire, whether through damage, destruction, or evacuation.

2. Economic Impact: Households that may have experienced economic setbacks due to the fire, including disruptions to employment, business operations, or income sources.

3. Community Engagement: Individuals actively involved in the affected community, fostering a community-centric approach to understanding the collective impact and needs.

4. Varying Demographics: Respondents may represent diverse demographic profiles, including age, income levels, family structures, and cultural backgrounds.

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5. Multi-Household Dynamics: Understanding the dynamics of households, especially those with varying family structures or shared living arrangements, to tailor assistance and support accordingly.

6. Specific Needs: Identification of specific needs arising from the fire, such as immediate housing, financial support, healthcare, or emotional well-being.

7. Geographic Location: Recognizing the geographical dispersion of impacted individuals and households to ensure a comprehensive understanding of the varied challenges faced.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey [ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ X ] Other: Claims Processing

CERTIFICATION:

I certify the following to be true:

1. The collection is required to obtain benefits.

2. The collection is non-controversial and does not raise issues of concern to other federal agencies.

3. FEMA needs to collect necessary information to perform these activities.

4. Usability testing has been completed on this instrument.

Digital Signature:

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ X ] Yes [ ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ X ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ X] Yes [ ] No

BURDEN HOURS: The estimated annual burden hours to respondents is 646,313 hours.

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals/Households	9,479	22.5	213,277 .5

For-Profit Businesses and Not-for-Profit Institutions	18,959	22.5	426,577 .5
State, local, and Tribal Government	287	22.5	6,457.5
Totals			646,313

FEDERAL COST: The estimated annual cost to the Federal government is $7,755,756.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe?

[ ] Yes [ X] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

Response: We plan to identify our potential group of respondents primarily through our existing database of claimants who have been affected by the fire and flood events. This database includes individuals who have submitted claims for assistance or have been identified through outreach efforts conducted by our program. Additionally, we will leverage our partnership with local government agencies, community organizations, and other stakeholders involved in disaster recovery efforts to reach out to potential respondents who may not be captured in our database.

The program will utilize a combination of methods including online forms, telephone interviews, and in-person meetings to reach out to our selected respondents. This multi-modal approach will allow us to accommodate the preferences and accessibility of different individuals within our target population, ensuring comprehensive coverage and maximizing response rates.

Overall, our strategy for identifying and selecting potential respondents is designed to be inclusive, representative, and efficient, enabling us to gather necessary data from those directly impacted by the Hermit's Peak Canyon fire and flood events.

Administration of the Instrument

1. How will you collect the information? (Check all that apply) [x]Web-based or other forms of social media

[x]Telephone [x]In-person [x] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [x] Yes [ ] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Instructions for completing Request for Approval under the “Generic Clearance for Notice of Loss and Proof of Loss”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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