DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
DEBT WAIVER ADJUSTED GROSS INCOME AFFIRMATION AND DECLARATION


FEMA requests the following information in order to administratively process your request for a waiver of debt, as authorized 
by the Disaster Assistance Recoupment Fairness Act of 2011:

*	Adjusted Gross Income (AGI) information must come from your most recent Federal tax return (2010 or 2011) as 
reported on Line 37 of Internal Revenue Service (IRS) Form 1040; Line 21 of Form 1040A; or Line 4 of Form 1040EZ. 
*	If Married Filing Separately, please add the AGI amounts from the individual tax returns together to determine the 
total household AGI. 
*	If you prefer, you may send in a copy of your most recently filed Federal income tax returns instead of completing the 
below statement. 


WARNING
Pursuant to Title 18 of the United States Code: Whoever knowingly and willfully falsifies, conceals, or covers up by any trick, scheme 
or device a material fact, or makes any materially false, fictitious or fraudulent statements or representations, may be fined up to 
$250,000, imprisoned, or both (18 U.S.C. §§ 287, 1001, and 3571).


My total household Adjusted Gross Income reported on my most recent Federal income tax return (2010 or 2011) is $__________.

My household does not file a Federal income tax return based upon the IRS requirements for my household’s filing status, age, and/or the 
type of income received.  My household income was $________ in 2011.  


By my signature, I certify and affirm, under penalty of perjury (28 U.S.C. § 1746) that: 
All information I have provided regarding my household’s Adjusted Gross Income is true and correct to the best of my knowledge. 
       
In addition to your certification below, FEMA may later require you to submit a copy of your Federal tax return.



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NAME (Print)	             		         	SIGNATURE				 DATE


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 DISASTER NUMBER	                         	REGISTRATION NUMBER		 	PHONE NUMBER

			
PRIVACY ACT STATEMENT

DHS/FEMA will use this information to process your waiver of debt pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act 
as amended, 42 U.S.C. § 5121-5207; The Privacy Act of 1974, 5 U.S.C. § 552a; The Federal Records Act, 44 U.S.C. § 301; and the Disaster 
Assistance Recoupment Fairness Act of 2011 (DARFA), Public Law 112-74 (December 23, 2011).  The information on this form may be used by and 
disclosed to DHS personnel, contractors, or others who need this information to assist in activities related to the principle purposes noted above, per the 
Routine Uses found in the DHS/FEMA 008 Disaster Recovery Assistance Files System of Records Notice, 74 Fed. Reg. 48763 (September 24, 2009), 
DHS/ALL 008 DHS Accounts Receivable System of Records Notice, 73 Fed.Reg.61885 (October 17, 2008), and DHS/ALL 013 DHS Claims System 
of Records, 73 Fed. Reg. 63987 (October 28, 2008).  The disclosure of this information is voluntary; however failure to provide the information will 
prevent DHS/FEMA from providing a waiver.

PAPERWORK BURDEN DISCLOSURE NOTICE
        
The information you provided above constitutes follow-up communications for ICR 1660-0002.  Obtaining the information above is authorized under 5 
C.F.R. § 1320.3(h) and 44 U.S.C. § 3518(c)(1)(B)(ii).  If you have any questions or concerns regarding the collection of the information above, please 
contact the FEMA helpline at 1-800-621-3362, or for individuals with hearing/speech impairment ONLY call 1-800-462-7585 (TTY).