TYPE OF CLAIM 

(Please submit a separate Notice of Loss for each type of claim.)

CLAIMANT CONTACT INFORMATION

DEPARTMENT OF HOMELAND SECURITY 

Federal Emergency Management Agency 

Hermit's Peak/Calf Canyon Claims Office 

NOTICE OF LOSS

OMB Control No. 1660-0159 

Expiration Date: 11/30/2026

By filing this Notice of Loss, you are choosing to seek compensation for losses from the Hermit's Peak/Calf Canyon Fire from the 

United States through the Hermit's Peak/Calf Canyon Fire Assistance Act (Act), Public Law 117-180, 136 Stat. 2177 (2022).

For the Hermit’s Peak/Calf Canyon Claims Office to consider your claim under the Act, you must sign the Verification of Truth 

of Information statement on Page 3 of this Notice of Loss. 

•

• The regulations governing the claims process may be found at 44 C.F.R. Part 296 and at http://www.fema.gov/hermits-peak.

• You may file your Notice of Loss up until November 14, 2024. 

You may submit your completed Notice of Loss to the Hermit's Peak/Calf Canyon Fire Claims electronically, through the U.S. 

mail, or in person. 

•

• As we review your claim, we will require additional information regarding your losses. 

For more information, please visit https://www.fema.gov/disaster/current/hermits-peak. 

Helpline phone number: 505-995-7133 

Claims Office Locations:

•

○ Mora Claims Office: Mora County Courthouse 1 Courthouse Drive Mora, NM 87732

○ Las Vegas Office: 208 Mills Ave, Suite 216, Las Vegas, NM 87701

○ Santa Fe Office: 1711 Llano Street, Suite E, Santa Fe, NM 87505 (Next door to Mucho Gourmet Sandwich Shoppe)

What type of claim are you filing? (check only one option)

Individual or Household

Business

Government

Tribal Nation

Not-for-Profit

Other:

Name (Entity who experienced the loss, or first, middle initial, last if filing as an individual or household) and contact information:

Name:

Telephone Number: Fax No.:

E-mail Address:

Best method to reach you:

FEMA Form FF-104-FY-22-230 (12/23) Page 1 of 6

Current Address:

City, State, Zip:

Damaged Property Address:

City, State, Zip:

phone call text email physical mail

Do you prefer to work with someone who speaks a language other than English? Yes No

If "Yes," please specify what language.

Accessibility: Any specific needs?
LOSSES

CLAIMANT CONTACT INFORMATION (Continued)

In general terms, describe the loss incurred by the claimant named above. You will be able to supplement this information 

during the claims process. Please do not submit documentation at this time. Detailed information on your losses and/or injuries and 

their dollar value will be requested and collected later during the claims process. 

Loss of property (examples: Damage to buildings and contents, damage to trees and vegetation; damage to vehicles or machinery, 

decrease in value of real property, damage to physical infrastructure, lost subsistence.) 

Business loss (examples: damage to tangible assets or inventory, business interruption, overhead, employee wages, loss of 

business net income.) 

Financial loss (examples: increased mortgage interest cost, insurance deductible, temporary living or relocation expenses, lost 

wages or personal income, emergency staffing, debris removal and clean-up, flood insurance, SBA loan.)

Additional pages may be attached.

FEMA Form FF-104-FY-22-230 (12/23) Page 2 of 6

Personal injury (examples: medical expenses, injury-related lost wages/personal income)

What are the claimant's names? 

(Including yourself, if you are a claimant)

What is this person's relationship to 

you? 

(examples: self, spouse, child)

If more space is required to identify additional claimants, please attach the information to this Notice of Loss.

Authorized Main 

Contact to Speak 

with Navigator?

Member's Date of 

Birth

Please provide the following information. Include everyone in your household who may speak to the Claims Office about your claim. 

(Note: Please list all individuals/stakeholders who have ownership or responsibility for the item claimed.)
INSURANCE AND OTHER ASSISTANCE 

(Responses to these questions will assist us in assigning a claims personnel and enable us to more efficiently process the claim.)

VERIFICATION OF TRUTH OF INFORMATION 

By filing this form all claimants whose names appear on this form attest that:

I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct. 

Primary claimant must sign:

Name (Print): Signature:

For an individual or household claim, all claimants named on this Notice of Loss, except minors, must sign. 

For a business, not-for-profit organization, pueblo, or government claim, an authorized official must sign.

Name (Print): Signature: Relationship or Title: Date:

FEMA Form FF-104-FY-22-230 (12/23) Page 3 of 6

Date:

4. Are you interested in receiving more information on the National Flood Insurance Program?

Yes No

5. Do you have a Conservation Restoration Plan with Natural Resources Conservation Service (NRCS)?

Yes No

3. Will you need a translator or special accommodations during the claims process?

Yes No If yes, please describe:

1. Have you filed an insurance claim for losses related to the Hermit's Peak/Calf Canyon Fire (whether or not the claim has 

been closed)?

Yes No If yes, please provide the name and contact information of the insurance company:

2. Did you receive a loan or grant from any of the following? Yes No

FEMA Grants (examples: Temporary Housing or Individual 

Assistance, Public Assistance, Mitigation)

U.S. Small Business Administration (SBA) Disaster Assistance

U.S. Department of Agriculture (USDA)

Environmental Protection Agency (EPA)

Indian Tribe

Not-for-Profit

State of New Mexico

Other:
AUTHORIZATION OF REPRESENTATION

CONSENT TO SHARE DATA WITH FEDERAL AND STATE PARTNERS

FEMA Form FF-104-FY-22-230 (12/23) Page 4 of 6

I authorize FEMA to share my information with the following Federal and/or State Partners:

I authorize FEMA to release the following information to the entities check above: 

NEW MEXICO DEPARTMENT OF HOMELAND SECURITY AND EMERGENCY MANAGEMENT (DHSEM) 

SMALL BUSINESS ADMINISTRATION (SBA)

A. Only my contact information which includes address, phone number, email address, work contract Yes No

information 

(Signature) (Date)

I, the undersigned Claimant, authorize disclosure of records pertaining to my Hermit’s Peak/Calf Canyon Fire Assistance Claim to:

(Name of Representative)

(Claimant Signature) (Date)

Third Party Representation Contact Information:

Title: Name: Address:

Phone Number: Fax Number: Email:

B. My claim file which includes amounts of awards, contact information, banking information, Social Security 

Number, etc. (Cross out information you do not want to share or list under “Other” and check NO.) 

Yes No

If additional resources may be available to me, or if other persons request information regarding my case, I authorize the information 

listed above to be released to: 

A. Partners offering assistance for unmet needs. Yes No

C. Other:

Complete this section only if you will be represented by a third party representative. 

To comply with 6 C.F.R. section 5.21 and allow access to records developed as part of your claim, any third party representative 

(including but not limited to attorneys, public adjustors, and family members), must provide the following:

Country of Citizenship or Residence of Claimant:

Place of Birth of Claimant:

Current Address of Claimant:

Full Name of Claimant:
ADDITIONAL INFORMATION 

Please provide details as to your losses and how this event has impacted your life:

FEMA Form FF-104-FY-22-230 (12/23) Page 5 of 6
 PAPERWORK BURDEN DISCLOSURE NOTICE

PRIVACY ACT 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 that FEMA has determined provided Hermit's Peak/Calf Canyon fire-related assistance to 

claimant 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.

e) When a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal or 

regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule, or order issued pursuant 

thereto, disclosure may be made to the appropriate agency, whether Federal, foreign, State, local, or tribal or other public authority 

responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation, 

or order issued pursuant thereto, if the information disclosed is relevant to any enforcement, regulatory, investigative or prosecutive 

responsibility of the receiving entity.

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.

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-22-230 (12/23) Page 6 of 6