PTA FEMA Form 009-0-131

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
PIA@hq.dhs.gov
Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.

Privacy Threshold Analysis – IC/Form

Page 1 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

Privacy Threshold Analysis (PTA)

Specialized Template for
Information Collections (IC) and Forms
The Forms-PTA is a specialized template for Information Collections and Forms. This
specialized PTA must accompany all Information Collections submitted as part of the
Paperwork Reduction Act process (any instrument for collection (form, survey,
questionnaire, etc.) from ten or more members of the public). Components may use this PTA
to assess internal, component-specific forms as well.
Form Number:

009-0-131

Form Title:

Sales Calculation Worksheet

Component:

Federal Emergency
Management Agency
(FEMA)

Office:

ORR

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Direct Housing Program Forms
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:

1660-0138
Extension

OMB Expiration
Date:
Date of last PTA (if
applicable):

August 31, 2018
April 30, 2015

PROJECT OR PROGRAM MANAGER
Brian G. Thompson
ORR
Title:
Unit Chief
540-686-3602
Email:
Brian.Thompson6@fema.dh
s.gov
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Elizabeth McDowell

Privacy Threshold Analysis – IC/Form

Page 2 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

Office:

ORR

Title:

Phone:

540-686-3630

Email:

Supervisory Program
Specialist
Elizabeth.McDowell@fema.d
hs.gov

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a
general description of the project and its purpose, including how it supports the DHS
mission, in a way a non-technical person could understand (you may use
information from the Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
The purpose of information collection request (ICR) 1660-0138 is to support the direct
housing mission. The information collected is necessary to determine the feasibility of a
potential site for placement of a Temporary Housing Unit (THU), to ensure the THU is
ready for purchaser occupancy, and to confirm applicant understanding of the
requirements of occupancy of the THUs, and to inform the purchaser of the requirements
and his/her responsibilities when buying a THU from FEMA. This information is
collected via paper forms, then uploaded into the Housing Operations Management
Enterprise Systems (HOMES) database used to coordinate the provision of THUs for
disaster survivors. HOMES is located within NEMIS- IA, the Individual Assistance IT
System which maintains the Individuals and Households Program information.
FEMA Form 009-0-131, Sales Calculation Worksheet, is used to advise FEMA Individual
Assistance applicants of the requirements for final sale of a THU, if FEMA offers a sale
program as part of its direct housing program, and to ensure the THUs are sold for a
price that is fair and reasonable. The first portions of the form consist of a calculator to
determine the Adjusted Fair Market Value (AFMV) of the THU and a worksheet to
determine the IHP Settlement Payment amount. These are completed by a FEMA
representative and submitted to a FEMA Sales Lead for review and approval. Once
approved, the FEMA representative provides the AFMV to the applicant.
If the applicant asserts they cannot afford to pay the AFMV, the Temporary Housing Unit
Sales Petition Calculator portion of the form may be used to determine an Adjusted Sales
Price. The calculator captures the applicant’s income, assets, the AFMV of the THU, and
the IHP Settlement Payment amount. The applicant’s income and assets must be
provided to the FEMA representative by the applicant, in order to receive an Adjusted
Privacy Threshold Analysis – IC/Form

Page 3 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

Sales Price. Upon completion, the form is submitted to the Sales Lead for review and
approval.
Once approved, the FEMA representative meets with the occupant in person to complete
the sale, reviews the final portion of the form with the occupant, the Acknowledgement
of Conditions of Sale, and both of them sign the form.
b. List the DHS (or component) authorities to collect, store, and use this information.
If this information will be stored and used by a specific DHS component, list the
component-specific authorities.
The Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, 42
U.S.C. § 5174 and Title 44 C.F.R. Part 206.117

2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII1)?

☒ Yes
☐ No

b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

☒ Members of the public
☒ U.S. citizens or lawful permanent
residents
☐ Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

c. Who will complete and
submit this form? (Check
all that apply.)

☒ The record subject of the form (e.g., the
individual applicant).
☐ Legal Representative (preparer, attorney,
etc.).
☐ Business entity.

1

Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred, including
any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident,
visitor to the U.S., or employee or contractor to the Department.
Privacy Threshold Analysis – IC/Form

Page 4 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

If a business entity, is the only
information collected business contact
information?
☐ Yes
☐ No
☐ Law enforcement.
☒ DHS employee or contractor.
☐ Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.
d. How do individuals
complete the form? Check
all that apply.

☒ Paper.
☒ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

e. What information will DHS collect on the form? List all PII data elements on the
form. If the form will collect information from more than one type of individual,
please break down list of data elements collected by type of individual.
 Applicant name
 Applicant Registration ID number
 Applicant current mailing address
 Applicant phone number
 Co-applicant name
 Disaster number
 Name of purchaser (if not the applicant)
 Sale price of the MHU
 Name of individual who prepared the form
 Printed name of the FEMA sales representative
 Signature of the FEMA Individual Assistance Branch Chief
 MHU Serial number
 MHU Vehicle Identification Number
 Purchaser’s signature
 Co-purchaser’s signature
 FEMA sales representative’s signature
Privacy Threshold Analysis – IC/Form

Page 5 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy







FEMA approving official’s signature
Purchaser’s Income information
Purchaser’s Asset Information
Purchaser’s Cash-in-Hand
FEMA Sales Lead’s initials

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply.
☐ Social Security number
☐ Alien Number (A-Number)
☐ Tax Identification Number
☐ Visa Number
☐ Passport Number
☐ Bank Account, Credit Card, or other
financial account number
☐ Other. Please list:

☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☐ Social Media Handle/ID
☐ Known Traveler Number
☐ Trusted Traveler Number (Global
Entry, Pre-Check, etc.)
☐ Driver’s License Number
☐ Biometrics

g. List the specific authority to collect SSN or these other SPII elements.
N/A
h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
N/A
i.

Are individuals
provided notice at the
time of collection by
DHS (Does the records
subject have notice of
the collection or is
form filled out by
third party)?

Privacy Threshold Analysis – IC/Form

☒ Yes. Please describe how notice is provided.
A Privacy Notice is provided on the first page of
the form.
☐ No.

Page 6 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
Click here to enter text.
completed IC/forms?
☒ Electronic. Please describe the IT system that will
store the data from the form.
The form is stored in the HOMES database within
NEMIS-IA as part of the applicant’s file.
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
HOMES database within NEMIS-IA
b. If electronic, how
does DHS input the
responses into the IT
system?

☐ Manually (data elements manually entered). Please
describe.
Click here to enter text.
☒ Automatically. Please describe.
The form is scanned and uploaded by JFO staff
into the HOMES database within NEMIS-IA.

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?
d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
that records are
disposed of or deleted

☒ By a unique identifier.2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Applicant name, Applicant Registration ID,
Applicant address
☐ By a non-personal identifier. Please describe.
Disaster assistance request information will be retained
in accordance with the National Archives and Records
Administration’s (NARA) record retention schedule and
FEMA’s Records Schedule N1-311-86-1, item 4C10a.
The program adheres to the disposition schedule
which provides timeframes for records destruction

2

Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity
of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of
whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.
Privacy Threshold Analysis – IC/Form

Page 7 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

in accordance with
and/or disposal of relevant documents associated
the retention
with the program.
schedule?
f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
☐ Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Click here to enter text.
☒ No. Information on this form is not shared outside of the collecting office.

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

Privacy Threshold Analysis – IC/Form

Page 8 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office Reviewer:

Heather K. Mills

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:

November 17, 2017

Have you approved a Privacy Act
Statement for this form? (Only
applicable if you have received a
waiver from the DHS Chief Privacy
Officer to approve component Privacy
Act Statements.)

December 5, 2017
☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
SORN:
 DHS/FEMA – 008 Disaster Recovery Assistance Files, 78 Fed. Reg. 25,282 (April 30,
2013).
PIA:
 DHS/FEMA/PIA – 027 National Emergency Management Information System Individual Assistance (NEMIS-IA) Web-based and Client-based Modules (June 29,
2012).
 Forthcoming DHS/FEMA/PIA XXX Individual Assistance Program

Privacy Threshold Analysis – IC/Form

Page 9 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Hannah Burgess

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1155141
December 15, 2017
December 15, 2018

DESIGNATION
Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

Determination:

☐ PTA sufficient at this time.
☐ Privacy compliance documentation determination in
progress.
☐ New information sharing arrangement is required.
☐ DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.
☒ Privacy Impact Assessment (PIA) required.
☒ System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.

DHS IC/Forms Review:

Choose an item.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
Choose an item.
Statement:
Privacy Notice submitted and approved
PTA:
Choose an item.
Click here to enter text.
PIA:
PIA in progress
Privacy Threshold Analysis – IC/Form

Page 10 of 11

Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, pia@hq.dhs.gov
www.dhs.gov/privacy

If covered by existing PIA, please list: Forthcoming Individual
Assistance PIA
If a PIA update is required, please list: Click here to enter text.
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/FEMA-008 Disaster
Recovery Assistance Files April 30, 2013 78 FR 25282
If a SORN update is required, please list: Click here to enter text.
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
FEMA is submitting this PTA to discuss the Sales Calculation Worksheet Form (FF
009-0-131). This form is part of OMB ICR 1660-0138, the purpose of which is to
support direct housing. When a disaster survivor is deemed eligible for a housing
unit, FEMA uses the forms in this information collection to determine the feasibility
of a potential site for temporary housing, to ensure the housing unit is ready for
occupancy, and to confirm applicant understanding of requirements.
Form 009-0-131 is used to advise Individual Assistance applicants of the
requirements for sale of a housing unit, if FEMA is offering a sale program as part of
the direct housing program, and to ensure that the housing unit is sold for a fair and
reasonable price. The form collects applicant contact information, purchaser income
and asset information, and the names and/or signatures of the purchaser, form
preparer, and FEMA sales representative.
The DHS Privacy Office agrees that form 009-0-131 is a privacy-sensitive collection,
requiring PIA coverage. Coverage is provided by the forthcoming Individual
Assistance PIA, which will cover all aspects of the Individual Assistance program,
including collection of PII in order to provide direct housing for disaster survivors.
SORN coverage is also required because information is retrieved by personal
identifier. Coverage is provided by DHS/FEMA-008 Disaster Recovery Assistance
Files, which covers information collected in order to provide disaster assistance to
applicants.
This PTA expires in one year. Two additional years of coverage will be provided
upon completion of the Individual Assistance PIA.

Privacy Threshold Analysis – IC/Form

Page 11 of 11

Version number: 04-2016