TYPE OF PROOF OF LOSS

AMOUNTS CLAIMED

CLAIMANT CONTACT INFORMATION

Claim Number:

For verification purposes, please provide one or more of the following:

Tax Identification Number

Business Identification Number

Other form of identification (Driver's license, Student ID, etc.)

Compensation under the Hermit’s Peak/Calf Canyon Fire Assistance Act is available to all injured persons, regardless of the 

citizenship or alien status of the individual.

What type of claim does this Proof of Loss cover? (Check only one option)

The following are the amounts claimed, by category, by the Claimant:

Medical Expenses

Medical Expenses 

Lost Personal Income

Real Property

Repair 

and is submitted 

pursuant to the Hermit's Peak/Calf Canyon Fire Assistance Act for injuries resulting from the Hermit’s Peak/Calf Canyon Fire.

DEPARTMENT OF HOMELAND SECURITY 

Federal Emergency Management Agency 

Hermit's Peak/Calf Canyon Claims Office 

PROOF OF LOSS

OMB Control No. 1660-0159 

Expiration Date: 11/30/2026

FEMA Form FF-104-FY-22-231 (12/23) Page 1 of 4

Name:

Current Address:

City, State, Zip:

Damaged Property Address:

City, State, Zip:

Phone Number: Fax No.:

E-mail Address:

Individual or Household

Business Government

Tribal Nation/Tribal Government

Not-for-Profit

Other:

$

$

$

$

$

$

$

Replacement

Decreased Value

Reforestation and/or Revegetation

Debris Removal and Other Clean-Up Costs

Personal Property

Address:

Partial Payment Proof of Loss Final Proof of Loss

Vehicles/Equipment $

$

Contents $

Other

This Proof of Loss relates to the Notice of Loss acknowledged by the Claims Office on 

$

NRCS Plan Estimates $

Decreased Value
Insurance Deductible

Other (Brief Description)

Individual Household Risk Reduction

Risk Reduction

Community Scale Risk Reduction

SBA Loan Repayment 

Business Interruption Expenses

$

$

$

$

$

$

$

$

FEMA Form FF-104-FY-22-231 (12/23) Page 2 of 4

Total Amount Claimed $

Write a statement describing the nature and extent of each injury for which you are requesting compensation. If you have any 

questions about the information to include with this Proof of Loss, please coordinate with your Navigator. Ensure that you write your 

name and claim number on all documents submitted with this form. If you are working with a Navigator, you may state that you have 

provided this documentation to them. Additionally, retain copies of all original documents and keep a copy of this Proof of Loss form 

for your records.

YOU MUST SIGN THE CERTIFICATION ON PAGE 3 BEFORE SUBMITTING THIS PROOF OF LOSS

Vehicle Insurance

Personal Property Insurance

Flood Insurance

Homeowner Insurance

Flood Policy Reimbursement

NFIP Policy Request $

$

Flood Insurance

Evacuation/Relocation

$

$

Temporary Housing/Relocation Expenses $

Moving and Storage Expenses

Evacuation Expenses
CERTIFICATION

This Proof of Loss consists of this form and the attached or previously submitted documents supporting the claim(s). The 

undersigned Claimant (or legal representative of the Claimant if a business or individual) declares under penalty of perjury under the 

laws of the United States that all the information on this form is true and correct. The undersigned Claimant (or legal representative 

of the Claimant if a business or individual) further certifies under penalty of perjury that no amount claimed in this Proof of Loss has 

been paid or will be paid by insurance, other assistance programs, or any other source. 

Individual and Household Claimants Sign Below:

1. Name of Claimant: 

Claimant Signature

3. Name of Claimant: 

5. Name of Claimant: 

7. Name of Claimant: 

Claimant Signature Date

Claimant Signature Date

6. Name of Claimant: 

Claimant Signature Date

Claimant Signature Date

4. Name of Claimant: 

Claimant Signature Date

Claimant Signature Date

Date

2. Name of Claimant: 

FEMA Form FF-104-FY-22-231 (12/23) Page 3 of 4

Please include additional signatures on another page if needed. 
PRIVACY ACT NOTICE

PAPERWORK BURDEN DISCLOSURE 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 who provided assistance to claimants related to the Hermit's Peak/Calf Canyon Fire, in 

order to ensure that benefits are not duplicated.

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.

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.

e) When a record, either independently or in conjunction with other records, suggests a violation or potential violation of the law--whether civil, 

criminal, or regulatory in nature, and whether arising under general statute, a particular program statute, or through a regulation, rule, or order 

issued pursuant thereto--disclosure may occur to the appropriate agency. This agency may be Federal, foreign, state, local, or another public 

authority responsible for enforcing, investigating, or prosecuting the violation. Additionally, disclosure may extend to entities charged with 

enforcing or implementing the relevant statute, rule, regulation, or order. The disclosed information is relevant to the enforcement, regulatory, 

investigative, or prospective responsibilities of the receiving entity.

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.”

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-22-231 (12/23) Page 4 of 4