Declaration of Need for Rental and/or Personal Property Assistance

(A) Applicant Information - Complete all applicant information lines.

FEMA Registration No:

Disaster No: 

 (Last Name, First Name, Middle Initial)

 (Street Address - Damaged Dwelling)

 (City, County, State)

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(B) Declaration for Displacement: Based on the information in your file and the answers you provide below, you may be eligible for rental and/or personal property assistance. Read the declaration carefully and provide your answers to all the questions. Then, sign the bottom of the declaration and return it to FEMA at the address or Fax number provided in the letter. A final determination of your eligibility will be made after we receive this signed declaration. You will be notified of our final eligibility determination in a separate letter.

1. Please provide the reason(s) why you are not currently living at your pre-disaster apartment / home? (Check all that apply)

__The apartment/home is unavailable for me to rent because of the disaster.

__I have not been able to contact my landlord to determine if my apartment/home is still available.

Other reason: 

2. Were you able to take any of your personal property with you when you evacuated, or retrieve any of your belongings after the disaster?
(Check all that apply)

__I was able to take ALL of my room furnishings (e.g., dining, living, and bedroom furniture) with me.

__I was NOT able to take any of my room furnishings with me.

__I was able to take SOME of my personal property with me (e.g. clothing, radio, books, toys, etc.) (Describe below)

3. Please check the statement(s) that describes your continuing need:

__I have a continuing need for rental assistance.

__I have a continuing need for personal property assistance.

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(C) Signature - Sign the declaration to indicate the information you have provided is true and correct to the best of your knowledge and that you understand the penalties for providing false information to obtain FEMA assistance.

I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain additional 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.

I hereby declare that, to the best of my knowledge, the information provided on this declaration is true and correct, and that I have a continuing need for Federal disaster housing and/or personal property assistance.

I hereby declare that, I do not own a secondary or vacation home within reasonable commuting distance of my pre-disaster residence.


Applicant's Signature 

Date