CLAIMANT CONTACT INFORMATION

INDIVIDUAL OR HOUSEHOLD

TYPE OF CLAIM 

AMOUNTS CLAIMED

Claim Number:

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

Social Security Number and/or Tax Identification Number

Business Identification Number

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

Note that 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)

This Proof of Loss relates to the Notice of Loss filed by the Claimant on

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

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

Personal Injury

Medical Expenses 

Lost Wages/Personal Income (Injury-Related)

Real Property

Repair 

and is submitted pursuant to the Hermit's

DEPARTMENT OF HOMELAND SECURITY 

Federal Emergency Management Agency 

Hermit's Peak/Calf Canyon Fire Assistance Act 

PROOF OF LOSS - HERMIT'S PEAK/CALF CANYON FIRE

OMB Control No. 1660-0155 

Expiration Date: 08/31/2023

FEMA Form FF-104-FY-22-231 (2/23) Page 1 of 5

Name:

Current Address:

City, State, Zip:

Damaged Property Address:

City, State, Zip:

Phone Number: Fax No.:

E-mail Address:

Individual or Household

Business Government

Indian Tribe

Not-for-Profit

Other:

$

$

$

$

$

$

$

$

Replacement

Decreased Value

Reforestation and/or Revegetation

Debris Removal and Other Clean-Up Costs

Heightened Risk Reduction

Personal Property

Address:

Final Proof of Loss Partial Proof of Loss

Vehicles/Equipment $

$

Contents $

Other
GOVERNMENT (STATE, TRIBAL OR LOCAL)

INDIVIDUAL OR HOUSEHOLD (Continued)

BUSINESS OR NON-PROFIT ORGANIZATION

Flood Insurance Premiums

Insurance Deductible

Temporary Living/Relocation Expense

Subsistence Resources

Other (Brief Description)

Personal Property

Business Interruption

Overhead Costs

Emergency Staffing Expenses

Employee Wages for Unperformed Work

Increased Mortgage Interest Costs

Flood Insurance Premiums

Insurance Deductible

Temporary Rental/Relocation Expense

Other

Increased Mortgage Interest Costs

$$$$$

Real Property

Repair $$$$$$$$$$$$$$

Replacement

$

Decreased Value

Reforestation and/or Revegetation

Debris Removal and Other Clean-Up Costs

Heightened Risk Reduction

FEMA Form FF-104-FY-22-231 (2/23) Page 2 of 5

Real Property

Repair $$$$$

Replacement

$

Decreased Value

Reforestation and/or Revegetation

Debris Removal and Other Clean-Up Costs

Heightened Risk Reduction

Personal Property

Address:

Address:

Total Amount Claimed$

Lost Wages/Personal Income (Not Injury-Related)$

Total Amount Claimed$

Vehicles/Equipment$$

Tangible Assets

$

Other

Inventory

$

Vehicles/Equipment$

Tangible Assets

$
GOVERNMENT (STATE, TRIBAL OR LOCAL) (Continued)

A statement describing the nature and extent of each injury for which compensation is sought must be attached to this Proof of Loss. 

Please coordinate with your Claims Reviewer if you have any questions about the information to include with this Proof of Loss. 

Write your name and claim number on all documents submitted with this form. Please keep all original documents and retain a copy 

of this Proof of Loss form for your records.

YOU MUST SIGN THE CERTIFICATION ON PAGE 4 BEFORE SUBMITTING THIS PROOF OF LOSS

FEMA Form FF-104-FY-22-231 (2/23) Page 3 of 5

$

$

Total Amount Claimed $

$

Increased Mortgage Interest Costs $

Temporary Rental/Relocation Expense

Tribal Subsistence Resources

Other

$

$

Emergency Staffing Expenses

Administrative Expenses

Firefighting Costs and Emergency Response $

$

$

Other

Inventory

Personal Property (Continued)
CERTIFICATION

This Proof of Loss consists of this form and the attached documents supporting the claim(s). The undersigned Claimant (or legal 

representative of the Claimant) declares under penalty of perjury under the laws of the United States that all of the information on 

this form is true and correct. The undersigned Claimant (or legal representative of the Claimant) 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: 

Date

Name of Claimant: 

Claimant Signature

Claimant Signature Date

Date

2. Name of Claimant: 

Other Claimants and Legal Representatives of Individual Claimants Sign Below:

Signature of duly authorized legal representative of Claimant 

Title of legal representative or Relationship to Claimant

FEMA Form FF-104-FY-22-231 (2/23) Page 4 of 5
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 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.

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 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 statuteor 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.

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 (2/23) Page 5 of 5