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
Atuunrirarkauluni November 30, 2025

PIYUNARQUCIRILRIIM IMIRARKAA AASSAQUUCIMAARKAT
NALLUNAIRUTET ALERQUUTIITGGUN
Una imirarkaq piurcimallruuq piyunarquciryugngaarkauluku Department of Homeland Security/Federal Emergency Management
Agency (FEMA) tunyugngaarkaurrluki nallunairutet unakumallret arenqiallugtellriit ikayurcetaaritnek imirillerpenek apertullerpenun.
Maligtaqutellriakun Privacy Act (PL 93-579) alerquutngurcimallruluni Congress-aakun 1974-aami, FEMA-m tunesciigatai
nallunairuceten igausngalriakun piyunarqucinrilkuvki (wall'u pinarqellriani alerquuciumalriakun). Imillren utercetniaran FEMA-mi
ikayurtevnun wall'u:
Kalikivigkun:
FEMA
P.O. Box 10055
Hyattsville, MD 20782-8055

Fax-aakun:
800-827-8112
Attn: FEMA

Computer-aakun:
www.DisasterAssistance.gov
Neggluku "Check Status" Home Page-aani
maligtaquluki-llu ayuqucirtuutet

ARCAQERTUQ: Maligtaqucuumiilkuvet nallunairutvet tunllerkaitnek alerquuciumanrituten, taugaam tunenrilkuvki
nallunairucet piyullrit wani imirarkami arenqianaqciquq ikayungcallerkarpenun FEMA-m allanun arenqiallugtellriit
ikayuutaitnun nallunairutvet tunenritellrit.

DRAFT

Atren (Kinguqlia, Ciuqlia, Qukaqlim Ayagnera)

FEMA Applicant FEMA Number-aan (PINGQERKUVET)

Yuurrvillren: Yuurrvillren (Atra, State-aa, Nunarpiim Atra)

Cami: Yuurtellerpet Erenra (mm-dd-yyyy)

SECTION A (PIYUKUVGU)

Piyunarquciraqa FEMA tunyugngaarkaurrluki nallunairutet apertullrenka kanani Section B-mi ukunun:
Atren (Kinguqlia, Ciuqlia)

(Elpenun tunesqekuvgu atren elliluku.)

Qayagaurcuutii

Address-aara

Qaill' Ilakucin

SECTION B
Piyunarquciraqa FEMA tunyugngariluki wani apertullrenka pagaani Section A-aami aterpagcimalrianun cali-llu/wall'u calivignun
kanani Section C-mi ukunek nallunairutnek:
Aa-ang

Qang'a

1. Imirama kalikautai, ilakluki yuvriucet nataqiillrit, qaill' amllertalriamek unangellemnek, unaksaramnek,
akiliurvigma nallunairutaitnek, Social Security Number-aamnek, allanek-llu. (Ceterluki nallunairucet
tunesqumanritellten wall'u igaulluki kanani igausngalriami "Allat" imirluku-llu Qang'a.)

Aa-ang

Qang'a

2. Unaksaranka, ilakluki kalikivigkun, qayagaurcuutekun, email-akun, calivimni unaksaranka, FEMA
Application Number-aaqa, allat-llu. (Ceterluki nallunairucet tunesqumanritelten wall'u igaulluki kanani
igausngalriami "Allat" imirluku-llu Qang'a.)

Aa-ang

Qang'a

3. Allat:

FEMA Form FF-104-FY-21-118-B (formerly 140-003d-1)
(8/23)

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SECTION C (PIYUKUVGU)
Allat arenqiallugtellriit ikayuutait paivngaskatki wangnun, wall'u allat yuut wiinga imirama nallunairutainek piyukata,
piyunarquciranka igausngalrianek pagaani Section B-aami tunyugngaluki ukunun.
Aa-ang

Qang'a

1. State-am calivii arenqiallugtellriit ikayuutaitnek paivcilriit

Aa-ang

Qang'a

2. Nunamteni, Avatemteni, State-ami, wall'u National Voluntary Organizations Active in Disaster
(NVOAD) ikayurtaitnun-llu

Aa-ang

Qang'a

3. Nunarpamta alerquuciurtainun calistaitnun-llu

Aa-ang

Qang'a

4. Qanemcistet calistait

Aa-ang

Qang'a

5. Allat:

Una piciutassiilria kituucirpenek cali-llu piyunarqucirilria tunyugngarivkarluki nallunairuceten piliaqumauq maligtaquulluni 28 U.S.C. §
1746. Akqiunga iqlulriit anucimirqecetaarutiitgun United States-aam alerquutaikun tamalkuita igausngalriit wani imirarkami
piciuqapigtellranek. Una piyunarqucirilria nallunairutemnek nangciquq ataucimi allrakumi sign-araartelluku.

DRAFT

Imirillrem Sign-allra

Enevet Uitavia

Atren Igaulluku

Erneq (mm-dd-yyyy)

AASSAQUCIMAARKAT ALERQUUTIITA QANQAUTIIT

PURPOSE: FEMA-m kaigatkaa nallunairutet igausngalriit wani kalikami aturluki kituucin piciutassiirarkauluku piyunarqucirarkaulu-llu
nallunairuceten tunarkaurrluki elpenun wall'u apertullerpenun wani imirarkami.
PIYUNARQUCIQ: Igausngalria piyunarquciryaraq maligtaqutuq Aassaqutarkat Alerquutiitnun Privacy Act of 1974, 5 U.S.C. §
552a(b). Calivik uumek imirarkamek aturyugngalria piyunarquciumauq uugun Robert T. Stafford Disaster Relief and Emergency
Assistance Act kitukaniumaciatun, 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); Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Pub. L. 104-193); cali-llu Exec. Order No. 13411.
ATUULAUCIIT: FEMA-m igalten wani imirarkami tunyugngai piyugngavkallrakun 5 U.S.C. § 552a(b) Privacy Act of 1974-ami,
kitukanillrakun, cali-llu "pilaucimegtun" nallunairutnek cikiqengllermegteggun allanun atanirturcet caliviitnun, kevgiulriit caliviitnun,
cali-llu allanun calivignun. Tamalkirtellriamek igausngalrianek atullrit nataqumayugngaut nallunairutmi DHS/FEMA-008 Disaster
Recovery Assistance Files Notice of System of Records, 78 Fed. Reg. 25,282 (Apr.30, 2013). Department-aam nallunairutai
igausngalriit nataqumayugngaut Department-aam website-aani http://www.dhs.gov/systemrecords-notices-sorns.

FEMA Form FF-104-FY-21-118-B (formerly 140-003d-1)
(8/23)

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