FEMA Form FF-104-F #4 Notice of Loss (English)

OMB Control No. 1660-0159
Expiration Date: XX/XX/20XX

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
Hermit's Peak/Calf Canyon Claims Office

NOTICE OF LOSS
By filing this Notice of Loss, you are choosing to seek compensation for losses from the Hermit's Peak/Calf Canyon Fire from the
United States through the Hermit's Peak/Calf Canyon Fire Assistance Act (Act), Public Law 117-180, 136 Stat. 2177 (2022).
• For the Hermit’s Peak/Calf Canyon Claims Office to consider your claim under the Act, you must sign the Verification of Truth
of Information statement on Page 3 of this Notice of Loss.
• The regulations governing the claims process may be found at 44 C.F.R. Part 296 and at http://www.fema.gov/hermits-peak.
• You may file your Notice of Loss up until November 14, 2024.
• As we review your claim, we will require additional information regarding your losses.
• You may submit your completed Notice of Loss to the Hermit's Peak/Calf Canyon Fire Claims electronically, through the U.S.
mail, or in person.
• For more information, please visit https://www.fema.gov/disaster/current/hermits-peak.
Helpline phone number: 505-995-7133
Claims Office Locations:
○ Mora Claims Office: Mora County Courthouse 1 Courthouse Drive Mora, NM 87732
○ Las Vegas Office: 208 Mills Ave, Suite 216, Las Vegas, NM 87701
○ Santa Fe Office: 1711 Llano Street, Suite E, Santa Fe, NM 87505 (Next door to Mucho Gourmet Sandwich Shoppe)

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TYPE OF CLAIM
(Please submit a separate Notice of Loss for each type of claim.)

What type of claim are you filing? (check only one option)
Individual or Household
Business
Government

Tribal Nation
Not-for-Profit
Other:

CLAIMANT CONTACT INFORMATION

Name (Entity who experienced the loss, or first, middle initial, last if filing as an individual or household) and contact information:
Name:

Current Address:
City, State, Zip:
Damaged Property Address:
City, State, Zip:
Telephone Number:

Fax No.:

E-mail Address:
Best method to reach you:

phone call

text

email

physical mail

Do you prefer to work with someone who speaks a language other than English?
If "Yes," please specify what language.

Yes

No

Accessibility: Any specific needs?

FEMA Form FF-104-FY-22-230 (12/23)

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CLAIMANT CONTACT INFORMATION (Continued)
Please provide the following information. Include everyone in your household who may speak to the Claims Office about your claim.
(Note: Please list all individuals/stakeholders who have ownership or responsibility for the item claimed.)
What are the claimant's names?
(Including yourself, if you are a claimant)

Member's Date of
Birth

What is this person's relationship to Authorized Main
you?
Contact to Speak
with Navigator?
(examples: self, spouse, child)

DRAFT

If more space is required to identify additional claimants, please attach the information to this Notice of Loss.

LOSSES

In general terms, describe the loss incurred by the claimant named above. You will be able to supplement this information
during the claims process. Please do not submit documentation at this time. Detailed information on your losses and/or injuries and
their dollar value will be requested and collected later during the claims process.
Loss of property (examples: Damage to buildings and contents, damage to trees and vegetation; damage to vehicles or machinery,
decrease in value of real property, damage to physical infrastructure, lost subsistence.)

Business loss (examples: damage to tangible assets or inventory, business interruption, overhead, employee wages, loss of
business net income.)

Financial loss (examples: increased mortgage interest cost, insurance deductible, temporary living or relocation expenses, lost
wages or personal income, emergency staffing, debris removal and clean-up, flood insurance, SBA loan.)

Personal injury (examples: medical expenses, injury-related lost wages/personal income)

Additional pages may be attached.

FEMA Form FF-104-FY-22-230 (12/23)

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INSURANCE AND OTHER ASSISTANCE

(Responses to these questions will assist us in assigning a claims personnel and enable us to more efficiently process the claim.)
1. Have you filed an insurance claim for losses related to the Hermit's Peak/Calf Canyon Fire (whether or not the claim has
been closed)?
Yes
No
If yes, please provide the name and contact information of the insurance company:

2. Did you receive a loan or grant from any of the following?

Yes

FEMA Grants (examples: Temporary Housing or Individual
Assistance, Public Assistance, Mitigation)
U.S. Small Business Administration (SBA) Disaster Assistance
U.S. Department of Agriculture (USDA)
Environmental Protection Agency (EPA)

No
Indian Tribe
Not-for-Profit
State of New Mexico
Other:

3. Will you need a translator or special accommodations during the claims process?
Yes
No
If yes, please describe:
4. Are you interested in receiving more information on the National Flood Insurance Program?
Yes
No

DRAFT

5. Do you have a Conservation Restoration Plan with Natural Resources Conservation Service (NRCS)?
Yes
No

VERIFICATION OF TRUTH OF INFORMATION

By filing this form all claimants whose names appear on this form attest that:

I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.
Primary claimant must sign:
Name (Print):

Signature:

Date:

For an individual or household claim, all claimants named on this Notice of Loss, except minors, must sign.
For a business, not-for-profit organization, pueblo, or government claim, an authorized official must sign.
Name (Print):

FEMA Form FF-104-FY-22-230 (12/23)

Signature:

Relationship or Title:

Date:

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AUTHORIZATION OF REPRESENTATION
Complete this section only if you will be represented by a third party representative.
To comply with 6 C.F.R. section 5.21 and allow access to records developed as part of your claim, any third party representative
(including but not limited to attorneys, public adjustors, and family members), must provide the following:
Full Name of Claimant:
Current Address of Claimant:
Place of Birth of Claimant:
Country of Citizenship or Residence of Claimant:
I, the undersigned Claimant, authorize disclosure of records pertaining to my Hermit’s Peak/Calf Canyon Fire Assistance Claim to:
(Name of Representative)
Third Party Representation Contact Information:
Title:

DRAFT
Name:

Phone Number:

Address:

Fax Number:

Email:

(Claimant Signature)

(Date)

CONSENT TO SHARE DATA WITH FEDERAL AND STATE PARTNERS

I authorize FEMA to share my information with the following Federal and/or State Partners:

NEW MEXICO DEPARTMENT OF HOMELAND SECURITY AND EMERGENCY MANAGEMENT (DHSEM)
SMALL BUSINESS ADMINISTRATION (SBA)
I authorize FEMA to release the following information to the entities check above:
A. Only my contact information which includes address, phone number, email address, work contract
information

Yes

No

B. My claim file which includes amounts of awards, contact information, banking information, Social Security
Number, etc. (Cross out information you do not want to share or list under “Other” and check NO.)

Yes

No

C. Other:

If additional resources may be available to me, or if other persons request information regarding my case, I authorize the information
listed above to be released to:
A. Partners offering assistance for unmet needs.

(Signature)

FEMA Form FF-104-FY-22-230 (12/23)

Yes

No

(Date)

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ADDITIONAL INFORMATION
Please provide details as to your losses and how this event has impacted your life:

DRAFT
FEMA Form FF-104-FY-22-230 (12/23)

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PRIVACY ACT NOTICE
This Notice is provided in accordance with the Privacy Act, 5 U.S.C. 552a(e)(3), and concerns the information requested in the Notice of Loss form
to which this Notice is attached. The authority for the collection of this information is Hermit's Peak/Calf Canyon Fire Assistance Act, Public Law
117-180. The information you provide will be used to verify your identity, to verify your eligibility, and to verify any previous compensation made in
connection with the Hermit's Peak/Calf Canyon Fire. Some or all of the information you provide may be released to federal, state, and local
government agencies or private organizations for the purpose of confirming your identity, your eligibility and any previous compensation or
payments made in connection with the Hermit's Peak/Calf Canyon Fire. The information may also be released when otherwise authorized by statute
or regulation. Disclosure of the information by you is required in order for you to make a claim under the Act. It will not be possible to process your
claim without the information.
Routine Uses: The Privacy Act permits us to disclose information about individuals without their consent for a routine use, i.e., when the information
will be used for a purpose that is compatible with the purpose for which we collected the information. The routine uses of this system are:
a) Disclosure may be made to agency contractors who have been engaged to assist the agency in the performance of a contract service related
to this system of records and who need to have access to the records in order to perform the activity. Recipients shall be required to comply
with the requirements of the Privacy Act of 1974, as amended, 5 U.S.C. 552a.
b) Disclosure may be made to a member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office
made at the written request of the constituent about whom the record is maintained.
c) Disclosure may be made to other Federal agencies that FEMA has determined provided Hermit's Peak/Calf Canyon fire-related assistance to
claimant in order to ensure that benefits are not duplicated.

DRAFT

d) Disclosure of information submitted by an individual claimant may be made to an insurance company or other third party which has submitted
a subrogation claim relating to such claimant when it is necessary in FEMA's opinion to ensure that benefits are not duplicated and to
efficiently coordinate the processing of claims brought by individuals and subrogees.
e) When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal or
regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule, or order issued pursuant
thereto, disclosure may be made to the appropriate agency, whether Federal, foreign, State, local, or tribal or other public authority
responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation,
or order issued pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative or prosecutive
responsibility of the receiving entity.
f) Disclosure may be made to the National Archives and Records Administration for the purpose of conducting records management studies
under the authority of 44 U.S.C. 2904 and 2906.
Effect of Failure to Respond: Disclosure is voluntary. However, failure to supply the requested information or to execute the form may render your
claim “invalid.”

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 45 minutes per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You
are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding
the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street. SW, Washington, DC 20472-3100, Paperwork Reduction Project
(1660-0155) NOTE: Do not send your completed form to this address.

FEMA Form FF-104-FY-22-230 (12/23)

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