Form FEMA Form FF-104-F FEMA Form FF-104-F Authorization for the Release of Information Under the P

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB No.1660-0061
Expires January 31, 2024

AUTHORIZATION FOR THE RELEASE OF INFORMATION UNDER THE PRIVACY ACT
The purpose of this form is to allow you to direct the Department of Homeland Security/Federal Emergency Management Agency
(FEMA) to release information collected for your disaster assistance application to any entity you choose. In accordance with the
Privacy Act (PL 93-579) passed by Congress in 1974, FEMA cannot release your information without your written consent (or an
exception provided by law). Please return the completed form to your FEMA point of contact or:
Mail to:
FEMA
P.O. Box 10055
Hyattsville, MD 20782-8055

Fax to:
800-827-8112
Attn: FEMA

Upload to:
www.DisasterAssistance.gov
Click "Check Status" on the Home Page and
follow the instructions

IMPORTANT: You are not obliged to give anyone access to information regarding you, but failure to provide the
information requested on this form may make it more difficult for FEMA to share your information with other disaster relief
entities to assist you.
Your Full Name (Last, First, MI)

FEMA Applicant Number (OPTIONAL)

Born At: Place of Birth (City, State/Province, Country)

On: Date of Birth (mm-dd-yyyy)

SECTION A (OPTIONAL)
I authorize FEMA to release information selected in Section B below to the following individuals:
Name (Last, First)
(To send your file to yourself, list your name.)

Telephone Number

Address

Relationship

SECTION B
I authorize FEMA to release to the individuals in Section A and/or the entities in Section C below the following information:
Yes

No

1. My case file, including inspection reports, amounts of awards, contact information, banking information,
Social Security Number, etc. (Cross out information you do not want to share or list under "Other'' and
check NO.)

Yes

No

2. My contact information, including address, phone number, e-mail address, work contact information,
FEMA application number, etc. (Cross out information you do not want to share or list under "Other'' and
check NO.)

Yes

No

3. Other:

FEMA Form FF-104-FY-21-118 (formerly 140-003d-1)
(3/21)

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SECTION C (OPTIONAL)
If additional disaster resources may be available to me, or if other persons request information regarding my case, I authorize the
information listed in Section B above to be released to:
Yes

No

1. State agencies offering disaster assistance

Yes

No

2. Local, Regional, State or National Voluntary Organizations Active in Disaster (NVOAD) and their partners

Yes

No

3. Members of Congress and their staff

Yes

No

4. Media representatives

Yes

No

5. Other:

This verification of identity and authorization to release records is made pursuant to and consistent with 28 U.S.C. § 1746. I declare
under penalty of perjury under the laws of the United States that all of my information on this form is true and correct. This
authorization to release records expires one year from the date of signing.

Signature of the Applicant

Current Address

Print Your Name

Date (mm-dd-yyyy)
PRIVACY ACT STATEMENT

PURPOSE: FEMA is requesting the information written on this form to establish your identity and your consent to share
your information with you or parties you have named in this form.
AUTHORITY: Written consent is requested pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a(b). The program for which
this form may be used is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended,
42 U.S.C. §§ 5121 -5207; The Homeland Security Act of 2002, 6 U.S.C. §§ 311-321j; Reorganization Plan No. 3 of 1978; 4 U.
S.C. §§ 2904 and 2906; 4 C.F.R. § 206.2(a)(27); the Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(Pub. L. 104-193); and Exec. Order No. 13411.
ROUTINE USES: FEMA may externally share the information you write in the fields on this form as generally permitted
under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, and as a “routine use” to facilitate information sharing
with other government agencies,voluntary agencies, and private entities. A complete list of the routine uses can be found
in the system of records notice DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records, 78 Fed.
Reg. 25,282 (Apr.30, 2013). The Department’s full list of systems of record notices can be found on the Department's
website at http://www.dhs.gov/system-records-notices-sorns.

FEMA Form FF-104-FY-21-118 (formerly 140-003d-1)
(3/21)

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