REC. # DEPARTMENT OF HOMELAND SECURITY O.M.B. No.

1660-0002 DR # Loss Date

61-4014840 FEDERAL EMERGENCY MANAGEMENT AGENCY 4673 2022-09-23

APPLICATION/REGISTRATION FOR DISASTER
Exp. 8/31/2022

(see reverse side) APP. DATE

ASSISTANCE 2022-10-04
1. Name of Applicant (last, first, MI) 2. Language 3. Date of Birth 4. Applicant Social Security No. 5. Email
BESSEL, RAOUL English 1957-05-11 XXX-XX-8037 [email protected]

6. Damaged Phone # Alt Damaged Phone# Alternate Cell Phone No.

7. Current Phone # (407) 898-3080
(321) 331-2921 Note:

8. Damaged Property Address No. Street Apt/Lot City. State Zip County
1215 DORCHESTER ST 1215 DORCHESTER ST ORLANDO FL 32803-1119 ORANGE
9. Mailing Address No. Street Apt/Lot City. State Zip
✔ Same as Damaged Address
10. Cause of Damage Flood Fire/Smoke/Soot/Ash Seepage Power Surge/Lightning ✔ Hail/Rain/Wind Driven Rain
Earthquake Sewer/Backup Ice/Snow Tornado Wind Other
11. Home Damage ✔ Yes No Unknown 12. Personal Property Damage ✔ Yes No 13. Utilities Out ✔ Yes No
14. Current Location Primary Home ✔ Hotel/Motel Family/Friends Mass Shelter Other

15. Residence Type: Travel Trailer Mobile Home Home-Single/Duplex Apt. Condo/Townhouse Other
✔

16, Primary Residence Yes No 17. Do You Own Rent 18. Is your home accessible? Yes
✔
✔

No, due to mandatory evacuation ✔ No, due to disaster

19. Home/Personal Property Insurance 20. Disaster Caused Expenses (for uninsured or underinsured expenses)

Insurance Type Insurance Company Name Expense Type YES NO IF YES and have insurance, Insurance Company Name
Medical X
Dental X

Funeral X

✔ I have no insurance for my home or personal property

21. Vehicle Damage Caused By Disaster

Vehicle Information Damaged? Drivable? Full Coverage Insurance? Liability Insurance? Insurance Company Name Registered?

Year Make Model YES NO YES NO YES NO YES NO YES NO

22. As a result of the disaster, do you have new or additional child care costs Yes ✔ No 23. Emergency Needs
or has your household income been reduced, increasing your financial burden ✔ Gas, Medication, or Food
✔ Shelter ✔ Clothing Durable Medical Equipment
to pay for child care?
24. Did you or anyone in your household use any type of mobility or assistive device such as a wheelchair, walker, cane, hearing aid, communication device, service animal, personal care attendant, or other
similarly medically-related devices or services that assist with disabilities or activities of daily living? Yes ✔ No
If yes, select all that apply:
Mobility: Cognitive/Developmental Hearing or Speech: Vision: Other:

Wheelchair Lift Disabilities/Mental Health: Hearing Aid TDD/TTY Glasses Braille or other accessible
Walker Bath Chair Personal Care Attendant Sign Language Text messaging and/or White Cane communication device

Cane Personal Attendant Other Interpreter other communication Service Animal Magnifier
device

25. Occupants living in primary residence at time of disaster

Last Name First Name MI Relationship Social Security Number Age Dependent?
(Applicant First, Please) YES NO
BESSEL RAOUL Registrant XXX-XX-8037 65 X

26. BUSINESS DAMAGES

Self Employment is primary income? ✔ YES NO Own/Represent a business or rental property affected by disaster? ✔ YES NO

27. Number of claimed dependents 1 29. Electronic Funds Transfer ✔ YES NO

Institution Name: XXXXXXXXX
28. Combined family pre-disaster gross income
$ ✔ Income Refused
Account Type: Checking Savings Routing No. XXXXXXXXX (9 digits)
Weekly Bi-Weekly Semi-Monthly Quarterly Yearly
XXXXXXXXX
Account No.:

30. Would you prefer to receive notification via traditional postal mail or E-mail? Postal Mail ✔
E-Mail 32. In which language would you like to receive letters?

English Spanish
31. Would you like to receive additional updates via text message? YES NO ✔
✔

33. Social Security Administration's Change of Address Request

When do you want this change to take effect? Make the change effective

34. Level of Damage to Home Minor damage but able to live in my home ✔ Damage to Home/Personal Property requires My home was destroyed
or Personal Property: Damage to Home/Personal Property and may not be able to live in my home major repairs. Not able to live in home Unknown

FEMA Form 009-0-1, July 12 REPLACES ALL PREVIOUS FEMA Form 90-69
 35. Comments 36. FEMA Representative

Application/Registration for Disaster Assistance Instructions

1. Enter the last name, first name, and middle initial of the application. Jr., Sr., etc. follow the last name.
2. Enter the language that the applicant speaks. If the applicant speaks English, leave blank.
3. Enter the date of birth of the applicant.
4. Enter the applicant's social security number (SSN). If the applicant does not provide a SSN, processing of the applicant may be delayed.
5. Enter e-mail address (if available).
6. Do NOT include a beeper/pager number in any of the phone number fields. Damaged Phone number: enter the phone number used in the applicant's home at the time of the
disaster even if the number is currently working.
7. Current Phone No. Enter the current phone number where the applicant can be reached. Alternate/Cell Phone No.: enter a work phone number or the phone number of a friend,
relative, or neighbor that FEMA can use to leave a message for the applicant. Note: include extension number (if available).
8. Enter the full physical street address at which the damage occurred. Do not enter a P.O. or general delivery address.
9. Enter the applicant's mailing address. It may or may not be the same as the Damaged Property Address or where the applicant is now living. The Mailing Address may be a post
office or general delivery address. If it is the same as the damaged property address, check the box for the same.
10. Check Cause of Damage (more than one cause may be checked). Other causes of damage may include explosion, drought, and riot. If more than the home was damaged (e.g., auto
was flooded), please describe in the Comments section in item No. 34.
11. If the applicant has damage to the home (e.g., electrical, heating, floors, walls, ceilings, and foundation), check Yes. If home damage is unknown, check Unknown.
12. If the applicant had Personal Property Damage, e.g., appliances, clothing, and/or furniture), check Yes.
13. If the applicant's utilities are not working (out), check "Yes." Utilities may include sewer, water, gas, electricity, and/or heating.
14. Check the current Location where the applicant is living.
15. Check the type of residence that was damaged (e.g., Travel Trailer, Mobile Home, House-Single/Duplex, etc.). Other may include, for example, homeless or RV.)
16. If the person lived in the home more than six months of the year, or the applicant lists it as the address of his/her Federal Tax Return, or the applicant files a homestead exemption,
or the applicant uses it as a voter registration address, check "Yes."
17. If the applicant is named on the deed, or the applicant maintains the home and pays the taxes but pays no rent, or the applicant has lifetime occupancy rights while not holding legal
title to the home, check Own. Check "Rent" if the applicant does not meet any of the above ownership criteria, even if the applicant pays no rent.
18. If the home is Accessible after the disaster, check "Yes." Inaccessible may include disruption or destruction of transportation routes or other obstructions that prevent the applicant
from gaining entry to the damaged home. If the applicant is unable to enter the home, determine if it's Due to the Disaster, or Due to Mandatory Evacuation and check appropriately.
19. List the type of insurance that the applicant held at the time of the disaster for the home and/or personal property, including but not limited to sewer backup, earthquake. Include the
name of the insurance company. If no insurance, check I have no insurance for my home or personal property.
20. If the applicant incurred a Medical, Dental, Funeral, and/or Moving Storage Expense related to the disaster, check "Yes." Under Insurance company, provide the name of applicant's
insurance company if they had insurance for that expense.
21. Enter all vehicles for the household (regardless of condition) and their year, make, and model. If the applicant or one of the applicant's dependents owns a vehicle(s) that was
damaged by the disaster, check "yes,." Also, check "Yes" for the vehicles that are drivable,. Check "Yes" if the listed vehicle(s) has Comprehensive and/or Liability Insurance, and if
the vehicle(s) is registered. Enter the name of the insurance company if applicant has insurance. If more space is needed, use the space in Item #29.
22. If the applicant had new or additional child care cost, or household income reduced and is causing a financial burden to pay child care check yes .
23. If the applicant has Emergency Needs (e.g, food, clothing, shelter), check the appropriate box for type of need.
24. Question relates to special needs. The Americans with Disabilities Act (ADA) defines a disability as "a physical or mental impairment that substantially limits one or more of the
major life activities of such individual." 42 USC 12102(2) (A). If the registrant or household member has such a disability and was affected by the disaster, please mark all of the
areas of disability that apply.
25. List information for the applicant and all other persons/dependents who consider the home to be their primary residence at the time of the disaster, whether or not they are related to
the applicant. It is important that the applicant's and co-applicant's SSN is included. Answer if they are a dependent or not.
26. SELF EMPLOYMENT IS PRIMARY INCOME? Check appropriately. OWNS/REPRESENTS BUSINESS OR RENTAL PROPERTY? Check appropriately.
27. Enter the number of claimed dependents as listed on the applicant's Federal Tax Return.
28. Enter the combined family pre-disaster gross Income. (This is the amount of income before any deductions, and may include money from employment, Social Security, retirement,
welfare, child support, stocks, interest, annuities, and savings or assistance from family and friends. It does not include food stamps or HUD Section 8 assistance.) Check the
appropriate frequency of pay (weekly, bi-weekly, monthly, semi-monthly, quarterly, or yearly). If income refused, check appropriate box.
29. If the applicant would like FEMA to automatically transfer assistance into their checking or savings account, check "Yes" next to Electronic Funds Transfer. Enter the name of the
applicant's financial institution. Enter the applicant's 9-digit routing no. (The routing no. is the 9-digit number that appears in the lower left hand corner of the check.) Indicate the
applicant's account type by marking the Checking or Savings box. Enter the applicant's account no. (The account number can be found at the center bottom of a check immediately
after the routing number, or can be found on a savings or checking account statement.) NOTE: Applicant name must be on the account.
30. Check how the applicant would like to receive correspondence. Postal Mail or E-mail
31. Select the language the applicant would like to receive correspondence. English or Spanish
32. If applicant would like to receive status updates via text message. Confirm Alternate Cell phone.
33. If applicable, enter Social Security Administration's Change of Address Request
34. Select the level of damage that best matches applicant's situation.
35. Enter any comments
36. Enter name of the FEMA representative filing out form.

PRIVACY Notice

AUTHORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records within this system under the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the
Stafford Act), Pub. L. No. 93-288, as amended, 42 U.S.C. §§ 5121-5207; 6 U.S.C. §§ 776-77, 795; the Debt Collection Improvement Act of 1996, 31 U.S.C. §§ 3325(d), 7701(c)(1); the Government
Performance and Results Act, Pub. L. No. 103-62, as amended; Reorganization Plan No. 3 of 1978; Executive Order 13411, “Improving Assistance for Disaster Victims,” August 29, 2006; and Executive
Order 12862 “Setting Customer Service Standards,” September 11, 2003, as described in this notice.

PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administrating financial assistance under a Presidentially-declared disaster. Additionally,
information may be reviewed internally within FEMA for quality assurance purposes and used to assess FEMA's customer service to disaster assistance applicants. FEMA collects the social security number
(SSN) to verify an applicant's identity and to prevent a duplication of benefits.

ROUTINE USE(S):
FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their disaster assistance files outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the
Privacy Act of 1974, as amended. FEMA may share the personal information of non-citizens, as permitted by the following Privacy Impact Assessments: DHS/FEMA/PIA-012(a) Disaster Assistance
Improvement Plain (DAIP) (Nov. 16, 2012); DHS/FEMA/PIA-027 National Emergency Management Information System - Individual Assistance (NEMIS-IA) Web-based and Client-based Modules (June 29,
2012); DHS/FEMA/PIA-015 Quality Assurance Recording System (Aug. 15, 2014). This includes sharing your personal information with federal, state, tribal, local agencies and voluntary organizations to
enable individuals to receive additional disaster assistance, to prevent duplicating your benefits, or for FEMA to recover disaster funds received erroneously, spent inappropriately, or through fraud as
necessary and authorized by routine uses published in DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records, 78 Fed. Reg. 25,282 (Apr.30, 2013) and upon written request, by
agreement or as required by law.

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: The disclosure of information, including the SSN, on this form is voluntary; however, failure to provide the information requested may delay
or prevent the individual from receiving disaster assistance.

PAPERWORK BURDEN DISCLOSURE NOTICE

009-0-1 (Paper Application)

Public reporting burden for this data collection is estimated to average 18 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. This collection of information is required to obtain or retain benefits. 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 St. SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0002) NOTE: Do not send
your completed form to this address.

It is not necessary to complete grayed fields.