FEMA Form FF-104-F Request to Stop Payment and Reissue Disaster Assistance

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-0061
Expires January 31, 2024

REQUEST TO STOP PAYMENT AND REISSUE DISASTER ASSISTANCE CHECK
Schedule Number:

Amount:

Due to circumstances beyond my control, I am not able to locate and/or cash the U.S. Department of the Treasury check issued to me
for disaster assistance from the Federal Emergency Management Agency (FEMA).
Therefore, I,

, would like to request that FEMA stop payment on the check previously issued

to me and reissue a check to me in the same amount.
I hereby declare under penalty of perjury that the foregoing is true and correct.

Signature

Date

My current mailing address is:

FEMA Form FF-104-FY-21-117 (formerly 009-0-96)
(3/21)

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