Form FF-104-FY-21-109 ( FF-104-FY-21-109 ( Transportable Temporary Housing Unit Request for the Sit

DEPARTMENT OF HOMELAND SECURITY

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

Federal Emergency Management Agency

TRANSPORTABLE TEMPORARY HOUSING UNIT REQUEST FOR THE SITE INSPECTION
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 its 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.

DRAFT

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.
SITE CONTROL NO. (As Assigned)

REGISTRATION NO.

SITE INFORMATION

APPLICANT INFORMATION

SITE ADDRESS (House Number & Street Name)

NAME (Last, First, Middle Initial)

CITY AND STATE

CURRENT ADDRESS (House Number & Street Name)

COUNTY/PARISH

NAME OF LANDOWNER

CITY AND STATE (Include Zip Code)

ADDRESS OF LANDOWNER

APPLICANT PHONE NUMBER
Primary:
Alternate:

LANDOWNER PHONE NUMBER
Primary:
Alternate:

SITE TYPE
Group Site

Private Site

Commercial Park

Other

NUMBER OF TTHUs REQUIRED
(Check One)
1

2

3

TYPE OF TTHU
MH

TT

PM

UFAS

SITE UTILITY INFORMATION (Completed by Site Inspector through inquiry to applicant)
UTILITY AND TYPE
ELECTRIC

COMPANY NAME

ACCESS AND FUNCTIONAL NEEDS

ADULTS

RAMP

GAS

ADA/UFAS Compliant Unit
Natural

WATER
Public
SEWER
Public

LP

None

Well

None

IS APPLICATION ON OXYGEN?
Yes
Septic

FAMILY COMPOSITION

No

Male:

Female:

CHILDREN
Male:

Female:

None

FEMA Form FF-104-FY-21-109 (formerly 010-0-9)
(12/21)

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LANDOWNER AVAILABLE TO
ACCOMPANY INSPECTOR TO SITE
Yes

APPLICANT SIGNATURE

DATE

No

SITE DESCRIPTION AND DIRECTIONS (Form DFO to Site - attach map if necessary)

NAME OF SITE INSPECTOR (Assigned by DHOP's Chief)
FLOODPLAIN-VELOCITY ZONE DETERMINATION
Within

INSPECTION APPOINTMENT
DATE
TIME

DATE ASSIGNED

1st Choice

DRAFT

Outside Restricted Zone

Flood Zone Map No.:

2nd Choice

APPLICANT ACTIONS TO MAKE SITE ACCEPTABLE

Site Feasible

Site Infeasible (State reason)

SIGNATURE OF SITE INSPECTOR

FF-104-FY-21-110, Landowner's Authorization/Ingress-Egress Agreement

DATE

APPLICANT NOTIFIED OF SITE DETERMINATION
Date:
By:

FEMA Form FF-104-FY-21-109 (formerly 010-0-9)
(12/21)

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