FEMA Form FF-104-F #3 Release and Certification (Entity)- Partial Payment (

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1600-0159
Expiration Date: XX/XX/20XX

Hermit's Peak/Calf Canyon Claims Office

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 “Claims 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 acknowledges that, to the extent that the partial payment represents compensation for actual costs, a partial payment in the
amount set forth above fully 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. Claimant agrees that the payment is final and
conclusive with respect to the severable portion of its injuries that are calculated based on actual costs, and that by accepting partial
payment for actual costs in the amount referenced above, Claimant 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. To the extent the partial payment is based on an estimated amount of damages for the loss, if actual costs to repair or replace
structures or infrastructure damaged by the Fire and cascading impacts, exceed the amount of the estimated partial payment, Claimant
understands that they may include the excess amount in the final Proof of Loss or request to reopen the claim as provided by law.
Claimant understands that by signing this Release and Certification – Partial Payment they reserve the right to continue to pursue
other claims under the Act not related to the severable portion of the losses identified on the Proof of Loss and to seek actual costs
to repair or replace structures or infrastructure damaged by the Fire in excess of an estimate if the partial payment is based on an
estimate. 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
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.
**Note: All individuals who have an ownership in the items being paid under this POL are required to sign this document.**
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Company Name:

Date Signed:

Printed Name:
FEIN:

Title:
DUNS Number:

Claim Number:

Phone Number:

Email Address (Optional):
FEMA Form FF-104-FY-22-253 (12/23)

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