Form FEMA Form FF-104-F FEMA Form FF-104-F Application for Continued Temporary Housing Assistance (

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-0061
Expiration Date: 05/31/2026

INDIVIDUALS AND HOUSEHOLDS PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR
CONTINUED TEMPORARY HOUSING ASSISTANCE
If you cannot return to your home due to disaster damage and you need help paying for a place to stay, FEMA may provide you Continued
Temporary Housing Assistance. In order to receive assistance for your temporary housing expenses, you must complete and send this form to
FEMA. FEMA will use the information in this form to confirm your eligibility for this assistance.
Please read these instructions before completing this form. If you have any questions or need help, call FEMA's Helpline at 1-800-621-3362.

DRAFT

Sections 1-6: Pre-filled Information
This section was filled in using information you gave FEMA when you applied for assistance. Review the information; if it is correct, move to Section
7: Housing Expenses. If your address or contact numbers are not correct, write the updated information in the space provided. If any other pre-filled
information is incorrect, call FEMA's Helpline at 1-800-621-3362.
Definitions:

Current Mailing Address: Address where you want FEMA to mail information about your request for disaster assistance.
Current Phone: Phone number that FEMA may use to contact you about your request for disaster assistance.
Section 7: Housing Expenses

In this section, list your household's current housing expenses. If you are a homeowner and still have housing expenses for your disaster-damaged
home, make sure to include them as well. You must send housing expenses documents, which may include.
HOMEOWNER EXPENSES FOR DAMAGED HOME
• Mortgage statement, real estate tax statement, and homeowners insurance (if paid separately from mortgage).
• If you still have essential utility expenses at your damaged home, see more info on how to include them under Temporary Housing Costs below.
TEMPORARY HOUSING COSTS
• Lease/rental agreement:
○ The lease or rental agreement must include the location of your home, amount of rent, length of lease, and number of occupants.
○ The lease must be signed by you or your co-applicant and the landlord.
• Rent receipts:
○ You must send rent receipts showing the date, location of the rental unit or home, and time period for which the rent payment applies.
You may also send receipts showing any paid security deposit.
○ Your receipts must show that you have used the Rental Assistance money FEMA sent you for temporary housing. This includes
expenses for hotels, motels, or other temporary housing.
• Essential Utilities:
○ You must provide bills or receipts for any gas, propane, electric, oil, trash, water, and sewer expenses you pay at your temporary home.
○ If you are a homeowner and still pay utilities at your damaged home and also at your temporary rental home, include the total amount
you pay for each utility and send bills or receipts for each.
Next to the type of expense, write the dollar amount of your bill or payment and select how often you are billed for that expense. Send a copy of the
document that shows how much you pay for each housing expense. You must send documents that can be verified.
EXAMPLE:
7. Housing Expenses (see instructions for definitions)
Expense

Current Amount

How often are you billed?

Mortgage

$1,495

(X) monthly ( ) annually ( ) other:

Real Estate Taxes

$1,600

( ) monthly ( ) annually (X) other: every 6 months

$700

( ) monthly ( ) annually (X) other: every 6 months

Home Insurance
Rent
Water, Sewer

$1,200
$100

(X) monthly ( ) annually ( ) other:
( ) monthly ( ) annually (X) other: every 3 months

FEMA Form FF-104-FY-21-115 (formerly 010-0-12) (3/24)

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INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR
CONTINUED TEMPORARY HOUSING ASSISTANCE (Continued)
Definitions:
Housing Expense: Any payments made for rent or mortgage (including principal, interest, and real estate taxes), home insurance, and utility costs
such as water, gas, propane, oil, trash, electricity, sewer. This does not include television, cable, internet, or telephone service.
Real Estate Taxes: Taxes paid on your damaged home. Only list this expense if the taxes are paid separately from your mortgage.
Home Insurance: Any type of insurance policy (such as homeowners, renters, flood, or earthquake insurance) that covers your damaged home.
Only list this expense if the insurance is paid separately from your mortgage.
Temporary Housing Unit: A house, apartment, condominium, manufactured home, recreational vehicle, or other dwelling where you are staying
temporarily. A rented room or group of rooms in a home with shared spaces (such as a kitchen, bathroom) may qualify as a housing unit only if
the area is generally available for rent to the public.

DRAFT

Section 8: Current Landlord Contact Information
Provide your current landlord's contact information.
Section 9: Income Information

Provide the income of each person aged 18 and older who is living with you at your temporary home. If anyone aged 18 and older in the home does
not have an income, list their name and “$0” in this section. You will need to provide a written explanation of why they don’t have an income. If
anyone in your household has more than one source of income, list each source separately. You must send copies of documents to verify any
income reported on the application. Documents may include:
• W-2 forms or tax returns from most recent tax year
• Recent pay stub
• Documentation of income from self-employment
• Documentation of government assistance, including Social Security
EXAMPLE:

9. Income Information (for each person aged 18 years and older living in the current home)
Name
Maria Quin

Gross Income
(before taxes)
$1,495.00

How often do you receive this income?
(X) monthly ( ) annually ( ) other:

Section 10: Permanent Housing
Select the box that best describes your housing situation before the disaster and your plan for permanent housing after the disaster. If known,
provide the date you expect to move into permanent housing. FEMA understands that recovery after a disaster takes time. You do not have to
complete Section 10 the first time you send FEMA this form. You will need to select a Permanent Housing Plan if you request additional
Continued Temporary Housing Assistance a second time.
Definition:
Permanent Housing Plan: A plan to return to your pre-disaster home after repairs are made or find another permanent home.
Section 11: Conditions
Read this section carefully. To be considered for Continued Temporary Housing Assistance, you must agree that each statement is true for your
situation.
Section 12: Declaration
Once you have completed the form, read the declaration statement, then sign and date the form.
Send the completed form to FEMA with copies of all supporting documents, such as pay stubs, mortgage statements, lease, utility bills,
rent receipts, etc.
If you have questions about this form or disaster assistance, call FEMA's Helpline at 1-800-621-3362 or visit www.DisasterAssistance.gov.
If you use a video relay service, captioned telephone service, or other communication services, please provide FEMA the specific number assigned
for that service.
If you feel that you have been discriminated against, you may contact the Civil Rights Unit within the Office of Equal Rights by email at
[email protected] or call 1-833-285-7448.

FEMA Form FF-104-FY-21-115 (formerly 010-0-12) (3/24)

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OMB Control No. 1660-0061
Expiration Date: 11/30/2025

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

INDIVIDUALS AND HOUSEHOLDS PROGRAM
APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1 hour 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. This collection of
information is required to obtain or retain benefits. 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 (1660-0061). NOTE: Do not send your completed application to this address.

DRAFT
PRIVACY ACT STATEMENT

PRINCIPAL PURPOSE: FEMA requests information to decide if you need help paying for temporary housing because of a disaster.

AUTHORITY: The Privacy Act of 1974 protects your rights as to how FEMA uses and shares your information with entities such as states, tribes,
local governments, and other organizations. The Stafford Act and other laws allow FEMA to collect information to determine eligibility and provide
assistance as a result of a Presidentially declared disaster.
ROUTINE USE: FEMA may share information you provide with other government agencies, volunteer organizations, and private groups, as allowed
by law. This is called a "routine use" and only shares information that is needed to provide disaster assistance. For a full list of routine uses, visit
www.dhs.gov and view "DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records."
DISCLOSURE: You are not required provide information requested in this form, but if you do not, you may not be eligible for additional FEMA
disaster assistance. If you have questions, please call FEMA's Helpline at 1-800-621-3362. If you use a video relay service, captioned telephone
service, or other communication services, please provide give FEMA the specific number assigned for that service.
1. APPLICANT NAME

4. FEMA APPLICATION NUMBER

2. DISASTER NUMBER

3. CURRENT MAILING ADDRESS

5. CURRENT PHONE

6. ALTERNATE PHONE

NOTE: If your mailing address or phone number(s) have changed, write the updated information below:

Important Notes: In addition to sending FEMA this completed form, you must also send documents to verify your housing expenses, such as your
current lease, rent receipts, and mortgage payment information, as well as current income documentation for each person in your household aged 18
years and older. You may also select the permanent housing plan that fits your situation, if this is not your first time completing this form.
7. HOUSING EXPENSES (see instructions for definitions)
If you are still responsible for housing expenses for your damaged home, also include those expenses below.
Expense

How often are you billed?

Current Amount

Mortgage

Monthly

Annually

Other:

Real Estate Taxes

Monthly

Annually

Other:

Home Insurance (any type of home insurance)

Monthly

Annually

Other:

Rent for Temporary Housing Unit

Monthly

Annually

Other:

Water, Sewer

Monthly

Annually

Other:

Electric

Monthly

Annually

Other:

Natural Gas, Oil, Propane

Monthly

Annually

Other:

Trash

Monthly

Annually

Other:

Other:

Monthly

Annually

Other:

FEMA Form FF-104-FY-21-115 (formerly 010-0-12) (3/24)

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8. CURRENT LANDLORD CONTACT INFORMATION
NAME

PHONE NUMBER

9. INCOME INFORMATION
Report income for each person aged 18 years and older living in your household. If anyone in your household is aged 18 years and older and does
not have any income, write their name and “$0” for their income.
You may attach a separate sheet of paper listing the name and income for each person aged 18 years and older in your household.
Gross Income
(before taxes)

Name

How often do you receive this income?
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly

Annually
Annually
Annually
Annually
Annually
Annually

Other:
Other:
Other:
Other:
Other:
Other:

DRAFT

10. PERMANENT HOUSING PLAN

I was RENTING my home at the time of the disaster and my permanent housing plan is to:
Return to my pre-disaster rental unit

Move into a new rental unit within my budget
Move in with family/friends

Projected move in date:

I OWNED my home at the time of the disaster and my permanent housing plan is to:
Repair or rebuild my disaster-damaged home

Build a new home at my disaster-damaged home address or at a new site
Purchase a different home
Become a renter and find a rental property within my budget
Move in with family/friends

Projected move in date:

11. CONDITIONS
Please read the following statements carefully. You may only receive Continued Temporary Housing Assistance if you meet all of the following
requirements:
• I still need help with temporary housing because I have used all previous FEMA Rental Assistance for temporary housing expenses, and I
don't have any other options to meet my temporary housing needs.
• My household does not receive assistance and is not eligible for housing assistance from another public agency such as the U.S. Department
of Housing and Urban Development, U.S. Department of Veterans Affairs, or any agency or organization providing housing.
• I do not own a secondary or vacation home within a reasonable distance of my disaster-damaged home that is available for my housing needs.
• I am looking for permanent housing within my budget that is within reasonable commuting distance from work and/or school.
The following applies only if you owned your disaster-damaged home and have decided to repair it:
• I have a plan to repair--or have started repairing-- my disaster-damaged home, and I intend to move back into it when the repairs are complete.
12. DECLARATION
NOTE: If you intentionally make false statements or hide information in order to receive disaster assistance, it is a violation of federal and state
laws. This may carry severe criminal and civil penalties. Penalties may include a fine up to $250,000, imprisonment, or both (18 U.S.C § 287, 1001,
and 3571).
I declare under penalty of perjury that the information I provided above is true and correct.

Applicant or Co-Applicant Signature

FEMA Form FF-104-FY-21-115 (formerly 010-0-12) (3/24)

Date

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