FF-104-FY-21-110 ( Transportable Temporary Housing Unit Landowner’s Authori

OMB Control Number: 1660-0030
Expires: January 31, 2024

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
TRANSPORTABLE TEMPORARY HOUSING UNIT LANDOWNER'S
AUTHORIZATION INGRESS-EGRESS AGREEMENT 1. REGISTRATION NO.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. This
collection of information is mandatory. You are not required to respond to this collection of information unless a valid 0MB control number appears in
the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:
Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington,
DC, 20472, Paperwork Reduction Project (1660-0030). Please do not send your completed survey to the above address.

PRIVACY ACT STATEMENT
AUTHORITY: 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.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of obtaining necessary landowner consent to inspect
site, place, maintain, deactivate and/or remove transportable temporary housing units (TTHUs) provided by FEMA to eligible applicants as part of
direct housing assistance under a Presidentially-declared disaster.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974,
as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster
Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by
law.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent the applicant from receiving disaster-related temporary housing assistance.

DRAFT

2. LANDOWNER'S INFORMATION
NAME

3. APPLICANT SITE INFORMATION

NAME

ADDRESS (House Number & Street Name)

SITE ADDRESS (House Number & Street Name)

CITY AND STATE (Include Zip Code)

CITY AND STATE (Include Zip Code)

PHONE NUMBER (Include Area Code)

NOTE: Provide directions and attach map if necessary

4. In consideration of the President's Disaster Declaration of

and the furnishing of a TTHU
(Date of declaration)

(DR#)

by the United States of America to the above applicant, a disaster survivor, and other good and valuable considerations not herein expressly stated,
and intending to be bound hereby, the Landowner (which term shall, for the purposes of this agreement, include the owner of record and any parties
in possession) does hereby agree with the applicant as follows:
a. The Landowner hereby certifies that they are the owner of the above described property and authorizes placement of a TTHU on their land
for use of the subject applicant for the period of assistance established by FEMA.
b. The Landowner agrees that no indebtedness of theirs will become a lien on the said TTHU, and that they will not attempt to restrain the owner
of the TTHU from removing it from the subject property.
c. The Landowner agrees to allow and maintain a route on ingress and egress for placing and removing the TTHU along and across the subject
property to the nearest reasonable access to a public street. This agreement includes the prohibition of structures and barriers upon the
property which would hinder or preclude the normal and usual connecting, parking, placing, hitching, or removing of the TTHU.
d. The Landowner further agrees to maintain a reasonable route of ingress and egress along and across the property to and from the TTHU for
the applicant.
e. The Landowner has agreed that the following alterations to the property may be made to assure adequate ingress and egress or to allow for
utility connections to existing utility service on the property. No claims will be filed by Landowner for these actions. (List removal of trees,
shrubs, fences, grading holes in driveway or foundation, etc.) Attach drawing of agreed-upon ingress and egress route.
5. This Agreement shall remain in force for 30 days following termination of occupancy of the TTHU in accordance with applicable Federal/State/
Local procedures and regulations.
6. Site preparation costs will be the responsibility of (Check One):
Provide details if responsibility is divided:
7. Landowner intends to charge and applicant agrees to pay

FEMA Form FF-104-FY-21-110 (formerly 010-0-10)
(12/21)

The applicant;

Landowner;

Other (Specify):

/month rent for use of the property.

(Mark "None" if no rent
is to be charged)

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8. SIGNATURE

DATE

a. OWNER/AGENT

b. APPLICANT

c. WITNESS

GENERAL INFORMATION
a. PURPOSE: The Landlord's Authorization is used to obtain the approval of the owner of a property for the placement and removal of a TTHU to be
used for temporary housing. The purpose of the Ingress-Egress is to obtain the approval of the owner/agent of a property through which a TTHU
must travel to reach a private site (generally properties adjacent to the proposed site) to ensure placement and removal of the TTHU.
b. RESPONSIBILITY: The applicant is responsible for obtaining the Landowner's Authorization from the owner of the proposed site. In an ingressegress situation, the applicant must obtain the Ingress-Egress Agreement from as many of the property owners as necessary to ensure adequate
ingress-egress for the site. The applicant will be provided the form by FEMA.
c. DISTRIBUTION:

DRAFT

Original - Applicant
Copy #1 - Direct Housing Logistics
Copy #2 - Landowner
Copy #3 - Applicant
Copy #4 - (Photocopy) Applicant Assistance

INSTRUCTION FOR COMPLETING FORM

Explain the procedure for placement of a TTHU and the reasons for requiring the Landowner's Authorization before giving the
applicant this document.
1. Registration Number: To be obtained from applicant Assistance.
2. Landowner Information: Provide complete name of legal owner of property and current address and telephone number where owner can be located.
3. Applicant Site Information: Give name and address. Provide detail instructions or map if location is not clear from address.
4. Give detail description of alterations that will be made and attach a clear map of agreed upon ingress-egress route(s).
5. Specify who will have responsibility for site preparation including clearance, provision of utilities, connection of utilities etc. (If responsibility is
divided, provide detailed explanation).
6. If owner does not intend to charge rent "None" should be marked in the blank provided.
7. Signature/Dates
a. Owner: Signature of individual legally empowered to enter into agreement regarding the property. May be owner or legal agent.
b. Applicant: Signature of head of household or other legally responsible member of household. Individual state laws must be observed in
determining legal responsibility. If adults not related by marriage (i.e., adult sisters/brothers, parent and adult child, college roommates, etc.)
All legally responsible adults must sign authorization.
c. Witness: The signing by the applicant and the owner/agent must be witnessed by someone unrelated to either party.

FEMA Form FF-104-FY-21-110 (formerly 010-0-10)
(12/21)

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