DEPARTMENT OF HOMELAND SECURITY
EMERGENCY PREPAREDNESS AND RESPONSE DIRECTORATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
DECLARATION AND RELEASE

O.M.B. NO. 1660-0002
Expires September 30, 2006

DECLARATION AND RELEASE

In order to be eligible to receive FEMA Disaster Assistance, a member of the household must be a citizen, non-citizen national or qualified alien of the United States.  Please read the form carefully, sign the sheet and return it to the Inspector, and show him/her a current form of photo identification.  Please feel free to consult with an attorney or other immigration expert if you have any questions.  

I hereby declare, under penalty of perjury that (check one):

1. I am a citizen or non-citizen national of the United States.

2. I am a qualified alien of the United States

3. I am the parent or guardian of a minor child who resides with me and who is a citizen, non-citizen national, or qualified alien of the United States.  Print full name and age of minor child: 

By my signature I certify that:
	
	* Only one application has been submitted for my household
	* All information I have provided regarding my application for FEMA disaster assistance is true and correct to the best of my knowledge. 
	* I will return any disaster aid money I received from FEMA or that State if I receive insurance or other money for the same loss, or if I do not use FEMA disaster aid money for the purpose for which it was intended.

	I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain disaster aid, it is a violation of federal and State laws, which carry severe criminal and civil penalties, including a fine up to $ 250,000, imprisonment, or both            (18 U.S.C. §§ 287, 1001, and 3571).

	I understand that, the information provided regarding my application for FEMA disaster assistance may be subject to sharing within the Department of Homeland Security (DHS) including, but not limited to, the Bureau of Immigration and Custom Enforcement.

	I authorize FEMA to verify all information given by me about my property/place of residence, income, employment and dependents in order to determine my eligibility for disaster assistance; and

	I authorize all custodians of records of my insurance employer, any public or private agency, bank financial or credit data service to release information to FEMA and/or the State upon request.

NAME (Print):


SIGNATURE:                                                                     

DATE OF BIRTH:          


DATE SIGNED:


INSPECTOR ID NO.:                                                    

FEMA APPLICATION NO.:                                          

DISASTER NO.:


ADDRESS OF DAMAGED PROPERTY:                                        

CITY:                                                           

STATE:                           


ZIP CODE:


PRIVACY ACT STATEMENT

The Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§ 5121-5206, Executive Order 12148, as amended, and Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 8 U.S.C. §§ 1601 et seq., authorize the collection of this information.  The primary use of this information is to determine your eligibility to receive FEMA disaster assistance.  Disclosures of this information may be made: Upon written request, to federal and state agencies providing disaster assistance, as well as to local governments or voluntary agencies from which you are seeking assistance, so that assistance efforts or benefits are not duplicated; to agencies, organizations and institutions as necessary for mitigation planning and enforcement; to law enforcement agencies or professional organizations where there may be a violation or potential violation of law; to a federal, state or local agency when we request information relevant to an Agency decision concerning issuance of a grant or other benefit, or in certain circumstances when a Federal agency requests such information for a similar purpose from us; to a Congressional office in response to an inquiry made at the request of the individual; to the Office of Management and Budget (OMB) in relation to private relief legislation under OMB Circular A-19; and to the National Archives and Records Administration in records management inspections conducted under the authority of 44       U.S.C. §§ 2904 and 2906.  Your social security number is solicited during registration pursuant to the Debt Collection Improvement Act of 1996, 31 U.S.C. §§ 3325 (d) and 7701 (c)(1).  Furnishing the social security number, as well as other information is voluntary, but failure to do so may delay or prevent provision of disaster assistance.

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 2 minutes per response.  The burden estimate includes the time for reviewing instructions, gathering data, and completing and submitting the form.  You are not required to complete this collection of information unless a valid O.M.B. control number is displayed in the upper right corner of this form.  Send comments regarding the accuracy of the burden and estimate and any suggestions for reducing the burden to: Information Collections Management, U.S. Department of Homeland Security, Emergency Preparedness and Response Directorate, Federal Emergency Management Agency, 500 C Street SW, Washington, DC 20472, Paperwork Reduction Project  (1660-0002).  NOTE: Do not send your completed form to this address.