Form FEMA Form FF-104-F FEMA Form FF-104-F Partial Payment Release and Certification Form (Entity)

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1600-0155
Expiration Date: XX/XX/XXXX

Hermit's Peak/Calf Canyon Fire Assistance Act

RELEASE AND CERTIFICATION (ENTITY) – PARTIAL PAYMENT
The undersigned Claimant filed a claim pursuant to the Hermit’s Peak/Calf Canyon Fire Assistance Act, Pub. L. No. 117-180, 136
Stat. 2114 (the “Act”) for damages resulting from the Hermit’s Peak/Calf Canyon Fire (the “Fire”) with the Hermit’s Peak/Calf Canyon
Claims Office (the “Office”). Pursuant to Section 104(d)(2) of the Act and after investigation, the Office determined that Claimant
suffered a partial compensable loss on a severable portion of its claim in the amount of $
.
Claimant hereby acknowledges that a partial payment in the amount identified above satisfies all of the Claimant’s outstanding
claims against the Federal Emergency Management Agency and/or the United States for any damage related to the severable
portion of its loss as described in the attached Proof of Loss. Further, Claimant agrees that the payment is final and conclusive with
respect to the severable portion of its injuries resulting from the Fire and that by accepting payment in the amount above is
completely and forever releasing the Federal Emergency Management Agency and the United States from any past present, and
future claims related to the severable portion of Claimant’s loss.
Claimant understands that by signing this Release and Certification – Partial Payment it reserves the right to continue to pursue
other claims under the Act not related to the severable portion of the losses identified on the attached proof of loss. Claimant further
understands that the decision to provide a partial payment cannot be appealed, but acceptance of a partial payment does not affect
its ability to pursue an appeal, arbitration, or other options under the Act with respect to any portion of a claim for which a Release
and Certification Form is not executed.

DRAFT

This Certification and Release constitutes the complete agreement of the parties and may only be amended by the written
agreement of both the Claimant and the Federal Emergency Management Agency.
I,

, under penalty of law, hereby proclaim that I am fully authorized to act on behalf of

authorized to act on behalf of the Claimant regarding all past, present, and future claims relating to the Hermit’s Peak/Calf Canyon
Fire Assistance Act. I understand that civil and/or criminal penalties may arise pursuant to the False Claims Act, 31 U.S.C. § 3729, et
seq., and/or other applicable law for any fraudulent statements or representations made in this regard.
Being a duly authorized and recognized representative and/or agent of the Claimant, I agree on behalf of the Claimant to the terms
and acknowledgments contained in this agreement.
I declare under penalty of perjury that the information I have provided regarding Claimant’s loss is true and correct.

Signed this

day of

Printed Name:

, 202

Signature:
Title:

Company Name:

Phone Number:

Current Mailing Address:
Damaged Property Address:
Email Address:

FEIN:

DUNS Number:

Claim Number:

FEMA Form FF-104-FY-22-253 (2/23)

Page 1 of 1