View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Generic Clearance for Notice of Loss and Proof of Loss
Agency IC Tracking Number:
Instruments #1-#6
IC Status:
Unchanged
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
44 CFR Part 269 (To search for a specific CFR, visit the
Code of Federal Regulations.
)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
FEMA Form FF-104-FY-22-231
#1 Proof of Loss (English)
FEMA Form FF-104-FY-22-231_V2_DRAFT.pdf
No
Printable Only
Form
FEMA Forn FF-104-FY-22-231-A
#1 Proof of Loss (Spanish)
FEMA Form FF-104-FY-22-231-A_V2_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-252
#2 Release and Certification (Individual/Household)- Partial Payment (English)
FEMA Form FF-104-FY-22-252_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-252-A
#2 Release and Certification (Individual/Household)- Partial Payment (Spanish)
FEMA Form FF-104-FY-22-252-A_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-253
#3 Release and Certification (Entity)- Partial Payment (English)
FEMA Form FF-104-FY-22-253_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-253-A
#3 Release and Certification (Entity)- Partial Payment (Spanish)
FEMA Form FF-104-FY-22-253-A_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-230
#4 Notice of Loss (English)
FEMA Form FF-104-FY-22-230_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-230-A
#4 Notice of Loss (Spanish)
FEMA Form FF-104-FY-22-230-A_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-254
#5 Request to Supplement Claim (English)
FEMA Form FF-104-FY-22-254_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-254-A
#5 Request to Supplement Claim (Spanish)
FEMA Form FF-104-FY-22-254-A_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-251
Banking Information Form (English)
FEMA Form FF-104-FY-22-251_DRAFT.pdf
No
Printable Only
Form
FEMA Form FF-104-FY-22-251-A
Banking Information Form (Spanish)
FEMA Form FF-104-FY-22-251-A_DRAFT.pdf
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Disaster Management
Subfunction:
Disaster Repair and Restore
Privacy Act System of Records
Title:
DHS/ALL-013 Department of Homeland Security Claims Records
FR Citation:
73 FR 63987
Number of Respondents:
28,725
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
28,725
0
0
0
0
28,725
Annual IC Time Burden (Hours)
696,581
0
0
0
0
696,581
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
#1 Generic Application- Proof of Loss
1660-0159 Generic Application POL-11-2023_Signed.pdf
01/17/2024
#2 Generic Application- Release and Certification (Indivivual/Household))
1660-0159 - Gen App FF-104-FY-22-252 (RC-House).pdf
01/17/2024
#3 Generic Application- Release and Certification (Entity)
1660-0159 - Gen App FF-104-FY-22-253 (RC Entity).pdf
01/17/2024
#4 Generic Application-Notice of Loss
1660-0159 - Gen App FF-104-FY-22-230 (NOL).pdf
01/17/2024
#5 Generic Application- Request to Supplement Claim
1660-0159 - Gen App FF-104-FY-22-254 (Supplement).pdf
01/17/2024
#6 Generic Application- Banking Information Form
1660-0159 - Gen App FF-104-FY-22-251 (Bank Info).pdf
01/17/2024
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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