Form FEMA Form FF-104-F FEMA Form FF-104-F Individuals and Households Program (IHP) – Supplemental

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-0061
Expires: XX/XX/XXXX

SUPPLEMENTAL APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
If you cannot return to your home due to disaster damage and you need help paying for a place to stay, FEMA may provide you
Continued Temporary Housing Assistance. You have previously received Continued Temporary Housing Assistance. In order to receive
more assistance for your temporary housing expenses, you must complete and send this form to FEMA. FEMA will use the information
in this form to confirm your eligibility for this assistance.
Please note: In order to receive additional assistance for your temporary housing expenses, you must have a permanent housing plan,
which is a plan to either move back to your pre-disaster home after repairs are made or find another permanent place to live. You must
also show that you are making progress on your plan.
Please read these instructions before completing this form. If you have questions or need help, call FEMA’s Helpline at
1-800-621-3362.
Sections 1-6: Pre-filled Information
This section was filled in using information you gave FEMA when you applied for assistance. Review the information; if it is correct,
move to Section 7: Documentation to Support Permanent Housing Plan.

DRAFT

If your address or contact numbers are not correct, write the updated information in the space provided. If any other pre-filled
information is incorrect, call FEMA’s Helpline at 1-800-621-3362.
Definitions:

Current Mailing Address: Address where you want FEMA to mail information about your request for disaster assistance.
Current Phone: Phone number that FEMA will use to contact you about your request for disaster assistance.
Section 7: PERMANENT HOUSING PLAN

You must send FEMA documents showing you are trying to find permanent housing. If you do not show you are making progress on
your permanent housing plan, FEMA may not approve your request for Continued Temporary Housing Assistance. To show you are
working on your permanent housing goal, you must:
• Send the documents listed on the chart in this section that support your permanent housing plan.
• Identify issues in Section 9 that may prevent you from moving into permanent housing by [DATE—end of period of assistance].
Definition:
Permanent Housing Plan: A plan to return to your pre-disaster home or find another permanent home.
Section 8: REQUEST FOR HELP
If you need help with your permanent housing plan, please mark the type of help you need in this section. FEMA may provide you
referrals to additional resources.
Section 9: PROGRESS CHALLENGES
Explain any issues you have that are delaying or preventing you from making progress on your permanent housing plan. Send any
supporting documents, including contact information for service providers when relevant.
Section 10: CONDITIONS
Read this section carefully. To be considered for Continued Temporary Housing Assistance, you must agree that each statement is true
for your situation.
Section 11: DECLARATION
Once you have completed the form, read the declaration statement, then sign and date the form.
Send the completed form to FEMA with copies of all supporting documents, such as pay stubs, mortgage statements, lease, utility bills,
rent receipts, etc.
If you have questions about this form or disaster assistance, call FEMA’s Helpline at 1-800-621-3362 or visit
www.DisasterAssistance.gov.
If you use a video relay service, captioned telephone service, or other communication services, please provide FEMA the specific
number assigned for that service.
If you feel that you have been discriminated against, you may contact the Civil Rights Unit within the Office of Equal Rights by email at
FEMA-CivilRightsOffice@fema.dhs.gov or call 1-833-285-7448.
FEMA Form FF-104-FY-22-228 (2/24)

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. 1660-0061
Expires: XX/XX/XXXX

INDIVIDUALS AND HOUSEHOLDS PROGRAM
SUPPLEMENTAL APPLICATION FOR CONTINUED TEMPORARY HOUSING ASSISTANCE
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1 hour 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. This collection of
information is required to obtain or retain benefits. 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 (1660-0061). NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT
PRINCIPAL PURPOSE: FEMA requests information to decide if you need help paying for temporary housing because of a disaster.

DRAFT

AUTHORITY: The Privacy Act of 1974 protects your rights as to how FEMA uses and shares your information with entities such as states, tribes,
local governments, and other organizations. The Stafford Act and other laws allow FEMA to collect information to determine eligibility and provide
assistance as a result of a Presidentially declared disaster.
ROUTINE USE: FEMA may share information you provide with other government agencies, volunteer organizations, and private groups, as allowed
by law. This is called a "routine use" and only shares information that is needed to provide disaster assistance. For a full list of routine uses, visit
www.dhs.gov and view "DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records."
DISCLOSURE: You are not required provide information requested in this form, but if you do not, you may not be eligible for additional FEMA
disaster assistance. If you have questions, please call FEMA's Helpline at 1-800-621-3362.
1. APPLICANT NAME

2. DISASTER NUMBER

3. CURRENT MAILING ADDRESS

4. FEMA APPLICATION NUMBER

5. CURRENT PHONE

6. ALTERNATE PHONE

NOTE: If your mailing address or phone number(s) have changed, write the updated information below:
NEW MAILING ADDRESS:

NEW PHONE NUMBER:

7. PERMANENT HOUSING PLAN
Permanent Housing Plan

Pre-Disaster
Housing Status

Repair disaster-damaged
home

Homeowner

Select documents you will send to show progress on your permanent housing plan:
Written statement explaining a timeline for completion, along with receipts for any repair
materials purchased
Contractor estimates, agreements, or other documents showing a timeline for repair
Permits for housing repair

Build new home

Homeowner

Written statement that includes a timeline for completion along with receipts for any building
materials purchased
Contractor estimates, agreements, or other documents showing a timeline for construction
Permits for housing construction

Purchase home

Homeowner or
Renter

Documentation of search for new home, such as a document showing you hired a realtor,
list of homes visited, offers submitted, closing date, etc.

Return to pre-disaster
rental home

Renter

Letter from landlord/property management showing repairs will be made to your pre-disaster
rental home, along with an estimated move-in date
Update on repair progress from landlord/property management

Move into new rental home

Homeowner or
Renter

Documentation of rental home search, which should include a list of landlords or property
management companies contacted
Verifiable reason why available housing does not meet your needs, such as the rental
homes are not within your budget, not accessible to a household member with a disability,
too far from school, work, medical providers, etc.

Move in with friend/family
member

Homeowner or
Renter

FEMA Form FF-104-FY-22-228 (2/24)

Written statement from the friend/family member who will be your landlord, showing the date
you can move into their home

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8. Request for Additional Assistance
If you need help making progress on your permanent housing plan, please mark the type of help you need and explain in the space below:
Help paying to repair/rebuild my pre-disaster home
Help with labor and/or materials to repair/rebuild my pre-disaster home
Help locating accessible housing because someone in my household has a disability
Help locating rental housing within my budget
Help signing up for public housing assistance or other subsidized housing
Help with something else
Explanation (you may also include the explanation on a separate page):

DRAFT

9. PROGRESS CHALENGES

If you have not been able to work on finding permanent housing, please mark the reason that applies to your situation and explain in the space below:
I or a member of my households was injured or suffered from a major medical condition
I can’t find affordable rental units or homes close to work or school
My landlord decided not to repair my pre-disaster rental
Shortages and/ or delays of contractors/labor and/or materials
Permit or local inspection delay
Insurance delay
Loss of income/work
Other reason

Explanation (you may also include the explanation on a separate page):

10. CONDITIONS
Please read the following statements carefully. You can only get Continued Temporary Housing Assistance if you meet all of the following
requirements.
NOTE: If the following statements do not apply to your situation, you are not eligible for Continued Temporary Housing Assistance and you do not
need to submit this form.
I understand that in order to be considered for Continued Temporary Housing Assistance, all the following must be true and accurate:
• I have used all previous FEMA Rental Assistance for temporary housing expenses, and I don't have any other options to meet my temporary
housing needs.
• My household does not receive assistance and is not eligible for housing assistance from another public agency such as the U.S. Department of
Housing and Urban Development, U.S. Department of Veterans Affairs, or any agency or organization providing housing.
• I do not own a secondary or vacation home within a reasonable distance of my disaster-damaged home that is available for my housing needs.
• I am looking for permanent housing within my budget that is within reasonable commuting distance from work and/or school.
The following applies only if you owned your disaster-damaged home and have decided to repair it:
• I have a plan to repair --or have started repairing-- my disaster-damaged home, and I intend to move back into it when the repairs are complete.
11. DECLARATION
NOTE: If you intentionally make false statements or hide information in order to receive disaster assistance, it is a violation of federal and state laws.
This may carry severe criminal and civil penalties. Penalties may include a fine up to $250,000, imprisonment, or both (18 U.S.C § 287, 1001, and
3571).
I declare under penalty of perjury that the information I provided above is true and correct.

Applicant or Co-Applicant Signature

FEMA Form FF-104-FY-22-228 (2/24)

Date

Date Form Mailed to Applicant

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