Request for Information (RFI) (Medical, Dental, Disability-Accessibility-Related Items)

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection 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 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 (1660-0002) NOTE: Do not send your completed form to this address.

FEMA Director Name Governor’s Name

FEMA Title Governor’s Title

FEMA Directorate Reference State of (State Name)

National Processing Service Center 00/00/0000

P.O. Box 10055

Hyattsville, MD 20782 – 7055

FEMA Application Number.000000000 Disaster Number: 0000

Applicant Name

Applicant Street Address

Applicant City, State, Zip

Dear Applicant Name:

Our records indicate you may have a need for the type(s) of assistance listed below. However, we need additional information to process your application. Please provide the following information within 21 days of the date of this letter:

Transportation losses:

1. Copy of title(s) for damaged vehicle(s).

2. Copy of current registration card(s) for damaged vehicle(s).

3. List all owned vehicle(s) (year, make & model) and a brief description of the damaged vehicle.

4. Verification of vehicle(s) expenses, an estimate or a bill from a mechanic verifying the repair costs and verifying that the damage to your vehicle(s) were caused by the disaster. Please include the name of the mechanic and company name, address and telephone number.

5. Verification of comprehensive insurance coverage settlement OR statement from you stating insurance coverage does not exist.

6. Explain the reason(s) there is a need for more than one vehicle.

7. Verification of liability insurance coverage settlement OR statement from you stating insurance coverage does not exist.

Mail your documents to: Fax your documents to:

FEMA – Applicant Services 1-800-827-8112

National Processing Service Center OR Attention: FEMA – Applicant Services

P.O. Box 10055

Hyattsville, MD 20782-8055

Include your FEMA Application Number and Disaster Number on all pages of your documents. Both numbers are printed at the top of the first page of this letter. Keep all originals for your records.

If we do not receive the information within 21 days, we will deny your request for this assistance and you will not be eligible.

If you have any questions, please call FEMA’s Helpline at 1-800-621-FEMA (3362). For people who are deaf, hard of hearing or with speech disabilities, the TTY is 1-800-462-7585.

Sincerely,

Individual Assistance Branch Director RFI