1660-0155 - Supporting Statement A - 2023 02 10 clean

February 10, 2023

Supporting Statement for

Paperwork Reduction Act Submissions

OMB Control Number: 1660 – 0155

Title: Notice of Loss and Proof of Loss

Form Number(s):

1. FEMA Form FF-104-FY-22-230/ FF-104-FY-22-230-A , Notice of Loss/ Notice of Loss (Spanish Translation);

2. FEMA Form FF-104-FY-22-231/ FF-104-FY-22-231-A, Proof of Loss/ Proof of Loss (Spanish Translation);

3. FEMA Form FF-104-FY-22-252/ FF-104-FY-22-252-A, Release and Certification Form (Partial Payment)/ Release and Certification Form (Partial Payment) (Spanish Translation);

4. FEMA Form FF-104-FY-22-253 / FF-104-FY-22-253-A,  Release and Certification Form Entity (Partial Payment)/ Release and Certification Form Entity (Partial Payment) (Spanish Translation);

5. FEMA Form FF-104-FY-22-254/ FF-104-FY-22-254-A,  Request to Supplement Claim/ Request to Supplement Claim (Spanish Translation);

6. FEMA Form FF-104-FY-22-251/ FF-104-FY-22-251-A, Banking Information/Banking Information (Spanish Translation)

General Instructions

A Supporting Statement, including the text of the notice to the public required by 5 CFR 1320.5(a)(1)(iv) and its actual or estimated date of publication in the Federal Register, must accompany each request for approval of a collection of information. The Supporting Statement must be prepared in the format described below and must contain the information specified in Section A below. If an item is not applicable, provide a brief explanation. When Item 17 or the OMB Form 83-I is checked “Yes”, Section B of the Supporting Statement must be completed. OMB reserves the right to require the submission of additional information with respect to any request for approval.

Specific Instructions

A. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information. Provide a detailed description of the nature and source of the information to be collected.

This information is necessary to support the Hermit’s Peak/Calf Canyon Fire Assistance Act (“Act”) implemented by the Hermit’s Peak/Calf Canyon Fire Assistance regulation (44 CFR part 296) which was added by FEMA’s November 14, 2022, Hermit’s Peak/Calf Canyon Fire Assistance Interim Final Rule (RIN 1660-AB14). The purpose of this authority is to ensure the expeditious consideration and settlement of claims to compensate victims of the Hermit’s Peak/Calf Canyon Fire.

The Act is intended to provide persons who suffered injuries as a result of Hermit’s Peak/Calf Canyon Fire with a simple, expedited process to seek compensation from the United States. To obtain benefits under this legislation, an Injured Person must submit all Hermit’s Peak/Calf Canyon Fire-related claims against the United States to FEMA. An Injured Person who elects to accept funds under the Act is barred from bringing a claim under the Federal Tort Claims Act or filing a civil action against the United States for damages resulting from the Hermit’s Peak/Calf Canyon Fire.

The first step in the process is to file a Notice of Loss with the Claims Office. The Claims Office will provide the Claimant with a written acknowledgement that the claim has been filed and the claim number. The Notice of Loss confirms that the Claimant has elected to initiate the process under the Act to seek compensation for injuries resulting from the Hermit’s Peak/Calf Canyon Fire and formally begins the claims process. Upon acknowledgment of the Notice of Loss, Claimants will have 150 days under the regulation to complete the Proof of Loss providing detailed information regarding their injuries. FEMA has a total of 180 days under the Act from the date it acknowledged the Notice of Loss to make a determination on the claim. In settling a claim, FEMA must determine: (1) whether the claimant is an injured person; (2) whether the subject injury resulted from the Hermit’s Peak/Calf Canyon Fire; (3) whether the person(s) is otherwise eligible to receive any amount determined; and (4) whether sufficient funds are available for payment and, if so, the amount.

This new collection is being submitted under the Emergency Process for approval of a valid OMB control number for a period of 6 months. Additionally, FEMA plans to seek public comments on the collection through the normal clearance process.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection. Provide a detailed description of: how the information will be shared, if applicable, and for what programmatic purpose.

The information is used by the Hermit’s Peak/Calf Canyon Fire Claims Office (“Claims Office”)

Use of FEMA Form FF-104-FY-22-230/ FF-104-FY-22-230-A serves to structure the information concerning the injuries sustained by claimants and formally begins the claims process. Each item of information requested is needed to establish the nature and scope of the claimant’s injuries and assign a Claims Reviewer to begin review of the claim. The information requested includes Claimant information (name, contact information including phone number, email address, and physical address); type of claim (individual/household, business, government, Indian Tribe, non-profit, other); description of losses in general terms (loss of property, business loss, financial loss); insurance information (company name, whether a claim has been filed with the company); FEMA grants received; other government assistance (Federal, State, local, Tribal); special needs assistance; and translation assistance.

Use of FEMA Form FF-104-FY-22-231/ FF-104-FY-22-231-A serves to further gather the specific details concerning the injuries sustained by Claimants to process the claim. Each item of information requested is needed to document and confirm the Claimant’s injuries. A Claims Reviewer will work directly with the Claimant to help Claimants better understand this form and how to complete it. The information requested includes Claimant information (name, contact information including phone number, email address, physical address and claim number); payment information and identity verification (social security number and/or tax identification number, business identification number, or other form of identification); type of claim (individual/household, business, government, Indian Tribe, non-profit, other); confirmation of the date the Claimant filed the Notice of Loss; amounts claimed by category by the Claimant on the claim for specific injuries for individuals/households (personal injury; real property; personal property; lost wages/personal income; increased mortgage costs; flood insurance premiums; insurance deductible; temporary living/relocation expenses; subsistence resources; other injuries); for businesses (real property; personal property/tangible assets/inventory; business interruption; overhead costs; emergency staffing expenses; employee wages for unperformed work; increased mortgage interest costs; flood insurance premiums; insurance deductible; temporary rental/relocation expense; other injuries); for government (real property; personal property/tangible assets/inventory; firefighting costs and emergency response; emergency staffing expenses; administrative expenses; temporary rental/relocation expenses; Tribal subsistence resources; other injuries); and the total amount of injuries/damages claimed.

Use of FEMA Form FF-104-FY-22-253/FF-104-FY-22-253-A serves to expedite payments where it is appropriate, while informing the entity that partial payment cannot be appealed, and acceptance of a partial payment does not affect the claimant’s ability to pursue an appeal, arbitration, or other options under the Act. The information requested includes Entity information (name, contact information including phone number, current mailing and damaged property address and claim number); payment information and identity verification (tax identification number, business identification number, or other form of identification, DUNS number, bank institution, bank routing number, and bank account number); final payment amount.

Use of FEMA Form FF-104-FY-22-252/FF-104-FY-22-252-A serves to expedite payments where it is appropriate, while informing the claimant that partial payment cannot be appealed, and acceptance of a partial payment does not affect the claimants’ ability to pursue an appeal, arbitration, or other options under the Act. The information requested includes Claimant information (name, contact information including phone number, current mailing and damaged property address and claim number); payment information and identity verification (social security number, or other form of identification, bank institution, bank routing number, and bank account number); final payment amount.

Use of FEMA Form FF-104-FY-22-254/ FF-104-FY-22-254-A serves to allow a claimant to supplement a claim to include additional claims any time before signing the Release and Certification. Claimants may request for Claims Director to consider one or more injuries not addressed in the Proof of Loss. Each item of the information requested is needed for documentation and administering supplementation procedures. The information requested includes Claimant information (name, contact information including phone number, email address, current mailing address and claim number), and explanation of why the injury was not previously reported.

Use of FEMA Form FF-104-FY-22-251/ FF-104-FY-22-251-A is intended to collect claimants banking information should a claimant opt for EFT (Electronic Funds Transfer) of either partial and/or final payment to their banking institution. The information requested includes Claimant information (name, contact information including phone number, email address, current mailing address and claim number), and Claimants Banking information (bank name, account type, routing number, and account number).

The Section 515 Information Quality Guidelines apply to this information collection and comply with all applicable information quality guidelines, i.e., OMB, FEMA, and specific operating unit guidelines.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

FEMA Forms FF-104-FY-22-230/ FF-104-FY-22-230-A, FF-104-FY-22-231/ FF-104-FY-22-231-A, FF-104-FY-22-252/ FF-104-FY-22-252-A, FF-104-FY-22-253/ FF-104-FY-22-253-A, FF-104-FY-22-254/ FF-104-FY-22-254-A, FF-104-FY-22-251/ FF-104-FY-22-251-A will be available via the Internet from the FEMA website https://www.fema.gov/hermits-peak and can also be downloaded as an electronically fillable form and transmitted electronically as an attachment to an e-mail. FEMA anticipates development and use of an online filing system in the near future.

Usability testing will be conducted during the renewal of this emergency collection.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above. 

Claimants are the best source of this initial information. Claimants must complete this form to elect to pursue a claim under the Act and provide the information on their injuries for the claims process. FEMA plans to leverage existing systems to verify the information provided by the Claimant, but the Claimant should provide all the requested information as part of the claims process.

5. If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize.

FEMA does not believe that this information collection has a significant economic impact on small businesses or other small entities. FEMA anticipates the use of a separate form in the future for small businesses if it is determined there is an impact on those entities.

6. Describe the consequence to Federal/FEMA program or policy activities if the collection of information is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

Providing this information is mandatory if the Injured Party seeks compensation under the Act pursuant to regulations at 44 CFR part 296. Injured Parties who do not provide this information will not be compensated under the Act. The information required to be provided on the Notice of Loss FEMA Form FF-104-FY-22-230 and Proof of Loss FEMA Form FF-104-FY-22-231 is generally available to the Injured Party, as it relates specifically to their injuries resulting from the Hermit’s Peak/Calf Canyon Fire. FEMA will assign a Claims Reviewer to assist those Injured Parties with the claims process after they submit the Notice of Loss, including obtaining supporting documentation that might not otherwise be generally available to the Injured Party and to assist in completing the Proof of Loss. FEMA anticipates the Claims Reviewer process will help reduce the burden on an Injured Party in this process.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner (See 5 CFR 1320.5(d)(2)):

1. Requiring respondents to report information to the agency more often than quarterly.

This information collection does not require respondents to report information more than quarterly.

2. Requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it.

This information collection does not require respondents to prepare a written response in fewer than 30 days after receipt of it.

3. Requiring respondents to submit more than an original and two copies of any document.

This information collection does not require respondents to submit more than an original and two copies of any document.

4. Requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years.

This information collection does not require respondents to retain records (other than health, medical, government contract, grant-in-aid, or tax records) for more than three years.

5. In connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study.

This information collection does not include a statistical survey.

6. Requiring the use of a statistical data classification that has not been reviewed and approved by OMB.

This information collection does not use a statistical data classification that has not been reviewed and approved by OMB.

7. That includes a pledge of confidentiality that is not supported by authority established in statue or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use.

This information collection does not include a pledge of confidentiality that is not supported by established authorities or policies.

8. Requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information’s confidentiality to the extent permitted by law.

This information collection does not require respondents to submit trade secrets or other confidential information.

8. Federal Register Notice: 



a. Provide a copy and identify the date and page number of publication in the Federal Register of the agency’s notice soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

This collection has been submitted as an emergency collection and comments were not solicited prior to approval by OMB. The agency is, however, also pursuing approval under the normal notice and comment process and will publish notice in the Federal Register for comment before receiving an extension of this approval.

 b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

c. Describe consultations with representatives of those from whom information is to be obtained or those who must compile records. Consultation should occur at least once every three years, even if the collection of information activities is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

The agency has completed some initial consultations with representatives of those from whom information is to be obtained or those who must compile records and anticipates ongoing engagement as part of the rulemaking and information collection process and is seeking comment on the interim final rule.

The Hermit’s Peak Fire began on April 6, 2022, after a prescribed burn exceeded the containment capabilities of the U.S. Forest Service and was declared a wildfire. On April 19, the Calf Canyon Fire began burning on Federal land and was later identified as the result of a pile burn in January 2022 that remained dormant under the surface before reemerging. The Hermit’s Peak and Calf Canyon Fires merged on April 27, 2022. By May 2, 2022, the fire had grown, causing evacuations in multiple villages and communities. President Biden issued a major disaster declaration for the counties of Colfax, Mora, and San Miguel, New Mexico on May 4, 2022. The U.S. Forest Service has assumed responsibility for the Hermit’s Peak/Calf Canyon Fire, which was not 100 percent contained until August 21, 2022. On September 30, 2022, Congress passed the Act authorizing FEMA to establish a claims process for victims of the Hermit’s Peak/Calf Canyon Fire.

Congress tasked FEMA with providing expeditious consideration and settlement of claims for injuries as a result of the Hermit’s Peak/Calf Canyon Fire. In doing so, Congress set strict deadlines around the claims process. First, FEMA was required to publish regulations establishing the process by November 14, 2022. Once the process was established in regulation, Claimants will have two years from the date the regulation was published to submit their Notice of Loss to FEMA. Without immediate access to the Notice of Loss, Claimants will not have the full period of time available under the statute to submit their claim. Once the Notice of Loss is acknowledged, Claimants will only have 150 days to submit their Proof of Loss for review by the Claims Office. The Proof of Loss documents the losses suffered by Claimants in detail to allow the Claims Office to complete review and issue a decision on the claim. Without immediate access to the Proof of Loss, Claimants will not have the full period of time available under the regulation to submit the additional information required to process their claim. It would thus be impracticable and contrary to the public interest to delay implementing this information collection until after FEMA has completed the PRA process.

Following the normal clearance procedures for approval of this information collection will also delay FEMA’s ability to expeditiously consider and settle claims arising from injuries as a result of the Hermit’s Peak/Calf Canyon Fire. Congress set a deadline in the Act for FEMA to process claims within 180 days of receipt of the Notice of Loss. FEMA cannot meet that deadline without Claimants having immediate access to the Notice of Loss and Proof of Loss forms. The victims of this Fire deserve compensation for their injuries and Congress has demanded immediate action to compensate them. It would thus be impracticable and contrary to the public interest to delay implementing this information collection until after FEMA has consulted with persons outside of the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment is issued directly as a result of the Notice of Loss or Proof of Loss.

FEMA will provide compensation payments as part of the Hermit’s Peak/Calf Canyon Fire Assistance process, as appropriate, at the conclusion of the process. FEMA anticipates that Claimants will sign a separate form at that stage of the process but has not yet finalized development of that document. The Notice of Loss in this information collection simply initiates the process by having the Claimant provide general information regarding the injuries suffered as a result of the Fires. The Proof of Loss requests more detailed information regarding the injuries suffered as a result of the Fires so that FEMA can fully review the claim.

10. Describe any assurance of confidentiality provided to respondents. Present the basis for the assurance in statute, regulation, or agency policy.

On November 8, 2022, the Privacy Threshold Analysis was adjudicated by the Department of Homeland Security. The system is covered by an existing Privacy Impact Assessment (PIA): DHS/FEMA/PIA-044 National Fire Incident Reporting System (NFIRS), and DHS/FEMA/PIA-049 Individual Assistance (IA) Program. The system is covered by an existing System of Records Notice: DHS/ALL-013, Department of Homeland Security Claims Records October 28, 2008, 73 FR 63179.

11. Provide additional justification for any question of a sensitive nature (such as sexual behavior and attitudes, religious beliefs and other matters that are commonly considered private). This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Provide estimates of the hour burden of the collection of information. The statement should:



a. Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated for each collection instrument (separately list each instrument and describe information as requested). Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desired. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.



b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I.

c. Provide an estimate of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. NOTE: The wage-rate category for each respondent must be multiplied by 1.45 and this total should be entered in the cell for “Avg. Hourly Wage Rate”. The cost to the respondents of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 13.

FF-104-FY-22-230/ FF-104-FY-22-230-A Notice of Loss – takes approximately 0.75 hours (45 minutes) to complete. FEMA estimates respondents at 28,725 in the first year and types of respondents include SLTs, For-Profit and Non-profit Businesses, and Individuals and Households. One percent of respondents are estimated to be SLTs at 287 and will submit one (1) Notice of Loss form for 215 (287 × 1 × 0.75) burden hours. FEMA estimates 66 percent of respondent are Businesses (including for-profit and non-profit) at 18,959 and will submit one (1) Notice of Loss form for 14,219 (18,959 × 0.75) burden hours. The remaining 33 percent of respondents are individuals and households estimated at 9,479 and will submit one (1) Notice of Loss form for 7,109 (9,479 × 0.75) burden hours. The total annual public burden is estimated to be 21,543 hours. This is based on 45 minutes of burden for each of 28,725 annual response.

FF-104-FY-22-231/ FF-104-FY-22-231-A Proof of Loss – takes approximately 22.5 hours to complete. FEMA estimates respondents at 28,725 in the first year and types of respondents include SLTs, For-Profit and Non-profit Businesses, and Individuals and Households. One percent of respondents are estimated to be SLTs at 287 and will submit one (1) Proof of Loss form for 6,457.5 (287 × 1 × 22.5) burden hours. FEMA estimates 66 percent of respondent are Businesses (including for-profit and non-profit) at 18,959 and will submit one (1) Proof of Loss form for 426,577.5 (18,959 × 22.5) burden hours. The remaining 33 percent of respondents are individuals and households estimated at 9,479 and will submit one (1) Proof of Loss form for 213,277.5 (9,479 × 22.5) burden hours. The total annual public burden is estimated to be 646,313 hours. This is based on 22.5 hours of burden for each of 28,725 annual response.

FF-104-FY-22-253/ FF-104-FY-22-253-A Release and Certification Form Entity (Partial Payment) – takes approximately 0.25 hours (15 minutes) to complete. FEMA estimates respondents at 28,725 in the first year and types of respondents include SLTs, For-Profit and Non-profit Businesses, and Individuals and Households. One percent of respondents are estimated to be SLTs at 287 and will submit one (1) Release of Certification Form Entity (Partial Payment) form for 71.75 (287 × 1 × 0.25) burden hours. FEMA estimates 66 percent of respondent are Businesses (including for-profit and non-profit) at 18,959 and will submit one (1) Release of Certification Form Entity (Partial Payment) form for 4,739.75 (18,959 × 0.25) burden hours. The remaining 33 percent of respondents are individuals and households estimated at 9,479 and will submit one (1) Release of Certification Form Entity (Partial Payment) form for 2,369.75 (9,479 × 0.25) burden hours. The total annual public burden is estimated to be 7,181.25 hours. This is based on 15 minutes of burden for each of 28,725 annual response.

FF-104-FY-22-252/ FF-104-FY-22-252-A Release and Certification Form (Partial Payment) – takes approximately 0.25 hours (15 minutes) to complete. FEMA estimates respondents at 28,725 in the first year and types of respondents include SLTs, For-Profit and Non-profit Businesses, and Individuals and Households. One percent of respondents are estimated to be SLTs at 287 and will submit one (1) Release of Certification Form (Partial Payment) form for 71.75 (287 × 1 × 0.25) burden hours. FEMA estimates 66 percent of respondent are Businesses (including for-profit and non-profit) at 18,959 and will submit one (1) Release of Certification Form (Partial Payment) form for 4,739.75 (18,959 × 0.25) burden hours. The remaining 33 percent of respondents are individuals and households estimated at 9,479 and will submit one (1) Release of Certification Form (Partial Payment) form for 2,369.75 (9,479 × 0.25) burden hours. The total annual public burden is estimated to be 7,181.25 hours. This is based on 15 minutes of burden for each of 28,725 annual response.

FF-104-FY-22-254/ FF-104-FY-22-254-A Request for Supplement Claim – takes approximately 0.17 hours (10 minutes) to complete. FEMA estimates respondents at 28,725 in the first year and types of respondents include SLTs, For-Profit and Non-profit Businesses, and Individuals and Households. One percent of respondents are estimated to be SLTs at 287 and will submit one (1) Request for Supplement Claim form for 48.79 (287 × 1 × 0.17) burden hours. FEMA estimates 66 percent of respondent are Businesses (including for-profit and non-profit) at 18,959 and will submit one (1) Request for Supplement Claim form for 3,223.03 (18,959 × 0.17) burden hours. The remaining 33 percent of respondents are individuals and households estimated at 9,479 and will submit one (1) Request for Supplement Claim form for 1,611.43 (9,479 × 0.17) burden hours. The total annual public burden is estimated to be 4,883.25 hours. This is based on 10 minutes of burden for each of 28,725 annual response.

FF-104-FY-22-251/ FF-104-FY-22-251-A Banking Information – takes approximately 0.33 hours (20 minutes) to complete. FEMA estimates respondents at 28,725 in the first year and types of respondents include SLTs, For-Profit and Non-profit Businesses, and Individuals and Households. One percent of respondents are estimated to be SLTs at 287 and will submit one (1) Banking Information form for 94.71 (287 × 1 × 0.33) burden hours. FEMA estimates 66 percent of respondent are Businesses (including for-profit and non-profit) at 18,959 and will submit one (1) Banking Information form for 6,256.47 (18,959 × 0.33) burden hours. The remaining 33 percent of respondents are individuals and households estimated at 9,479 and will submit one (1) Banking Information form for 3,128.07 (9,479 × 0.33) burden hours. The total annual public burden is estimated to be 9,479.25 hours. This is based on 20 minutes of burden for each of 28,725 annual response.

Estimated Annualized Burden Hours and Costs
Type of Respondent	Form Name / Form No.	No. of Respondents	No. of Responses per Respondent	Total No. of Responses	Avg. Burden per Response (in hours)	Total Annual Burden (in Hours)	Avg. Hourly Wage Rate	Total Annual Respondent Cost
State, Local, & Tribal Government	FF-104-FY-22-230 Notice of Loss	287	1	287	0.75	215	$89.21	$19,180
State, Local, & Tribal Government	FF-104-FY-22-231 Proof of Loss	287	1	287	22.5	6,458	$89.21	$576,118
State, Local, & Tribal Government	FF-104-FY-22-251 Banking Information	287	1	287	0.33	95	$89.21	$8,475
State, Local, & Tribal Government	FF-104-FY-22-253 Partial Payment Release and Certification Form Entity	287	1	287	0.25	72	$89.21	$6,423
State, Local, & Tribal Government	FF-104-FY-22- 254 Request to Supplement Claim	287	1	287	0.17	49	$89.21	$4,371
For-Profit Businesses and Not-for-Profit Institutions	FF-104-FY-22-230 Notice of Loss	18,959	1	18,959	0.75	14,219	$80.34	$1,142,354
For-Profit Businesses and Not-for-Profit Institutions	FF-104-FY-22-231 Proof of Loss	18,959	1	18,959	22.5	426,578	$80.34	$34,271,277
For-Profit Businesses and Not-for-Profit Institutions	FF-104-FY-22-253 Partial Payment Release and Certification Form Entity	18,959	1	18,959	0.25	4,740	$80.34	$380,812
For-Profit Businesses and Not-for-Profit Institutions	FF-104-FY-22-254 Request to Supplement Claim	18,959	1	18,959	0.17	3,223	$80.34	$258,936
For-Profit Businesses and Not-for-Profit Institutions	FF-104-FY-22-251 Banking Information	18,959	1	18,959	0.33	6,256	$80.34	$502,607
Individuals and Households	FF-104-FY-22-230 Notice of Loss	9,479	1	9,479	0.75	7,109	$40.61	$288,696
Individuals and Households	FF-104-FY-22-231 Proof of Loss	9,479	1	9,479	22.5	213,278	$40.61	$8,661,220
Individuals and Households	FF-104-FY-22-252 Partial Payment Release and Certification Form	9,479	1	9,479	0.25	2,370	$40.61	$96,246
Individuals and Households	FF-104-FY-22-254 Request to Supplement Claim	9,479	1	9,479	0.17	1,611	$40.61	$65,423
Individuals and Households	FF-104-FY-22-251 Banking Information	9,479	1	9,479	0.33	3,128	$40.61	$127,028
Total		143,625		143,625		689,401		$46,409,166

Instruction for Wage-rate category multiplier: Take each non-loaded “Avg. Hourly Wage Rate” from the BLS website table and multiply that number by 1.45 for not-for-profit institutions, for-profit businesses, and individuals and households. Multiply the non-loaded “Avg. Hourly Wage Rate” by 1.61 for State, Local or Tribal Government. ¹ For example, a non-loaded BLS table wage rate of $42.51 would be multiplied by 1.45 for not-for-profit institutions and 1.61 for State, Local or Tribal Government, and the entries for the “Avg. Hourly Wage Rate” would be $61.64 and $68.44 respectively.

According to the U.S. Department of Labor, Bureau of Labor Statistics², the May 2021 Occupational Employment and Wage Estimates of the average wage for General and Operations Managers (SOC 11-1021) is $55.41 per hour and the wage rate for All Occupations (SCO 00-0000) is 28.01 per hour. Including the wage rate multipliers of 1.45 and 1.61, the fully-loaded hourly wage rates are $80.34 ($55.41 × 1.45) for businesses (for-profit and non-profit), $89.21 ($55.41 × 1.61) for State, Local or Tribal Government respondents, and $40.61 (28.01 × 1.45) for individuals and households.

The annual burden hour cost is estimated to be $46,409,166 ((SLTs = 6,889 hours × $89.21 = $614,567) + (Businesses = 455,016 × $80.34 = $36,555,985) + (Individuals and Households = 227,496 × $40.61= $9,238,613)+(1 due to rounding)).

The information reported on FEMA Form FF-104-FY-22-230 Notice of Loss is used by the Claimant to a claim for injuries resulting from the Hermit’s Peak/Calf Canyon Fires for review by FEMA for possible compensation under the Act. FEMA estimates that each response would require 0.75 hour (45 minutes) to complete including management time and clerical time.

FEMA Form FF-104-FY-22-230/ FF-104-FY-22-230-A, Notice of Loss is prepared as the first step in the claims process. A Claimant will submit this form one time as part of the process. FEMA anticipates electronic submission of this form will reduce the burden. No meaningful estimate of this anticipated reduction in burden is available at this time. A Claimant may need to submit additional information demonstrating their injuries as part of the process. The Notice of Loss form simply initiates the process for the Claimant and puts FEMA on notice that the Claimant suffered injury and that the Claimant has elected to initiate a claim under the Act.

FEMA Form FF-104-FY-22-231/ FF-104-FY-22-231-A, Proof of Loss is submitted after a Claimant has submitted the Notice of Loss and coordinated with a Claims Reviewer to assist them with information needed to complete the Proof of Loss form. A Claimant may submit Proofs of Loss as part of a partial payment and also a final Proof of Loss. FEMA anticipates electronic submission of this form will reduce the burden. No meaningful estimate of this anticipated reduction in burden is available at this time. A Claimant will need to submit supporting documentation and information with the Proof of Loss demonstrating their injuries as part of the process and the Claims Reviewer will assist with that process.

FEMA Form FF-104-FY-22-253/ FF-104-FY-22-253-A, Release and Certification Form Entity (Partial Payment) is submitted after a Claimant has submitted the Notice of Loss and Proof of Loss and coordinated with a Claims Reviewer to assist them with information. A Claimant will submit this form one time as part of the process. FEMA anticipates electronic submission of this form will reduce the burden. No meaningful estimate of this anticipated reduction in burden is available at this time. Receipt by a claimant of a partial payment is contingent on the claimant signing a Release and Certification Form for the severable part of the claim for which partial payment is being made.

FEMA Form FF-104-FY-22-252/ FF-104-FY-22-252-A, Release and Certification Form (Partial Payment) is submitted after a Claimant has submitted the Notice of Loss and Proof of Loss and coordinated with a Claims Reviewer to assist them with information. A Claimant will submit this form one time as part of the process. FEMA anticipates electronic submission of this form will reduce the burden. No meaningful estimate of this anticipated reduction in burden is available at this time. Receipt by a claimant of a partial payment is contingent on the claimant signing a Release and Certification Form for the severable part of the claim for which partial payment is being made.

FEMA Form FF-104-FY-22-254/ FF-104-FY-22-254-A, Request to Supplement Claim form is submitted after a Claimant has submitted the Notice of Loss and Proof of Loss. A Claimant will submit this form one time as part of the process. FEMA anticipates electronic submission of this form will reduce the burden. No meaningful estimate of this anticipated reduction in burden is available at this time. A Claimant may amend the Notice of Loss to include additional claims at any time before signing the Release and Certification.

FEMA Form FF-104-FY-22-251/ FF-104-FY-22-251-A, Banking Information form is submitted after a Claimant has submitted the Notice of Loss. A Claimant will submit this form one time as part of the process. FEMA anticipates electronic submission of this form will reduce the burden. No meaningful estimate of this anticipated reduction in burden is available at this time. A Claimant will submit this form to the claims office for the purpose of partial and final payments.

Usability testing will be conducted during the renewal of this emergency collection. The burden hours will be confirmed at that time.

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. (Do not include the cost of any hour burden shown in Items 12 and 14.)

The cost estimates should be split into two components:

a. Operation and Maintenance and purchase of services component. These estimates should take into account cost associated with generating, maintaining, and disclosing or providing information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred.

There are no operation or maintenance costs associated with this information collection.

b. Capital and Start-up-Cost should include, among other items, preparations for collecting information such as purchasing computers and software, monitoring sampling, drilling and testing equipment, and record storage facilities.

There are no capital or start-up costs associated with this information collection.

14. Provide estimates of annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing and support staff), and any other expense that would have been incurred without this collection of information. You may also aggregate cost estimates for Items 12, 13, and 14 in a single table.



Annual Cost to the Federal Government
Item	Cost ($)
Contract Costs: Vendor to process claims and build system of record	$53,990,155
Staff Salaries: 45 employees at GS12, Step 5 in Washington, DC locality spending approximately 100% of time annually inputting processing SPA requests for the data collection. (45 x $106,759 = $4,804,155) ($4,804,155 x 100% = $4,804,155) ($4,804,155 x 1.45 wage rate = $6,966,024.75 (rounded up))	$6,966,025
Facilities: Lease for Santa Fe - $1,000,000 Lease for Mora - $39,822.02 Lease for Las Vegas - $750,000 Security Guards for Santa Fe, Mora, and Las Vegas $1,000,000 ($1,000,000 + $39,822.02 + $750,000 + $1,000,000 = $2,789,822.02 (rounded down))	$2,789,822
Computer Hardware and Software [cost of equipment annual lifecycle]: Copiers and printers = $15,000 Office copiers = $40,000 Telecom Services - phones, laptops, internet at $3,000/month = $36,000 ($15,000 + $40,000 + $36,000 = $91,000)	$91,000
Equipment Maintenance [cost of annual maintenance/service agreements for equipment]: Servers, building start up, badges, phones, laptops = $640,000	$640,000
Travel (not to exceed): Travel from DC to NM 34 people making six (6) trips per year at $2,500/trip. (34 people x 6 trips = 204 total trips) (204 x $2,500 cost per trip = $510,000)	$510,000
Other: Office Supplies = $116,000	$116,000
Total	$65,103,002
1 Office of Personnel Management 2023 Pay and Leave Tables for the Washington-Baltimore-Arlington, DC-MD-VA-WV-PA locality. Available online at https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/DCB.pdf. Accessed January 20, 202.3 2 Wage rate includes a 1.45 multiplier to reflect the fully-loaded wage rate

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I in a narrative form. Present the itemized changes in hour burden and cost burden according to program changes or adjustments in Table 5. Denote a program increase as a positive number, and a program decrease as a negative number.

A “Program increase” is an additional burden resulting from an Federal Government regulatory action or directive. (e.g., an increase in sample size or coverage, amount of information, reporting frequency, or expanded use of an existing form). This also includes previously in-use and unapproved information collections discovered during the ICB process, or during the fiscal year, which will be in use during the next fiscal year.

A “Program decrease”, is a reduction in burden because of: (1) the discontinuation of an information collection; or (2) a change in an existing information collection by a Federal Agency (e.g., the use of sampling (or smaller samples), a decrease in the amount of information requested (fewer questions), or a decrease in reporting frequency).

An “Adjustment” denotes a change in burden hours due to factors over which the government has no control, such as population growth, or in factors which do not affect what information the government collects or changes in the methods used to estimate burden or correction of errors in burden estimates.

Itemized Changes in Annual Burden Hours
Data Collection Activity/Instrument	Program Change (hours currently on OMB inventory)	Program Change (new)	Difference	Adjustment (hours currently on OMB inventory)	Adjustment (new)	Difference
FF-104-FY-22-230/ FF-104-FY-22-230-A, Notice of Loss	0	21,543	21,543
FF-104-FY-22-231/ FF-104-FY-22-231-A, Proof of Loss	0	646,312.5	646,312.5
FF-104-FY-22-252/ FF-104-FY-22-252-A, Release and Certification (Partial Payment)	0	4,906	4,906
FF-104-FY-22-254/ FF-104-FY-22-254-A, Request to Supplement Claim	0	9,433	9,433
FF-104-FY-22-251/ FF-104-FY-22-251-A, Banking Information	0	7,205	7,205
Total	0	689,401	689,401

Explain: This is a new information collection. Therefore, no historical data is available and all of the estimates in this information collection are new.

Itemized Changes in Annual Cost Burden
Data Collection Activity/Instrument	Program Change (cost currently on OMB inventory)	Program Change (new)	Difference	Adjustment (cost currently on OMB inventory)	Adjustment (new)	Difference
FF-104-FY-22-230 Notice of Loss	$0	$1,450,230	$1,450,230
FF-104-FY-22-231 Proof of Loss	$0	$43,508,509	$43,508,509
FF-104-FY-22-252/ FF-104-FY-22-252-A, Release and Certification (Partial Payment)	$0	$330,782	$330,782
FF-104-FY-22-254/ FF-104-FY-22-254-A, Request to Supplement Claim	$0	$634,006	$634,006
FF-104-FY-22-251/ FF-104-FY-22-251-A, Banking Information	$0	$485,533	$485,533
Total	$0	$46,409,166	$46,409,166

Explain: This is a new information collection. Therefore, no historical data is available and all of the estimates in this information collection are new.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no outlined plans for tabulation and publication of data for this information collection beyond the Act’s requirement to submit annual reports to Congress describing the claims submitted under the Act.

17. If seeking approval not to display the expiration date for OMB approval of the information collection, explain reasons that display would be inappropriate.

This collection does not seek approval to not display the expiration date for OMB approval.

18. Explain each exception to the certification statement identified in Item 19 “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.



This collection does not seek exception to “Certification for Paperwork Reduction Act Submissions.”

1 Bureau of Labor Statistics, Employer Costs for Employee Compensation, Table 1.  “Employer costs per hour worked for employee compensation and costs as a percent of total compensation:  Civilian workers, by major occupational and industry group, March 2022.”  Available at https://www.bls.gov/oes/2021/may/oes192041.htm.  Accessed on October 13, 2022.  The wage multiplier for not-for-profit institutions is calculated by dividing total compensation for all workers of $40.35 by wages and salaries for all workers of $27.83 per hour yielding a benefits multiplier of approximately 1.45. The wage multiplier for State, Local, or Tribal Government is calculated by dividing total compensation for State and local Government workers of $54.96 by Wages and salaries for State and Local Government workers of $34.09 per hour yielding a benefits multiplier of approximately 1.61.

2 Information on the mean wage rate from the U.S. Department of Labor Bureau of Labor Statistics is available online at: https://www.bls.gov/oes/2021/may/oes_nat.htm Accessed on October 13, 2022.

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