Tele-Registration Application For Disaster Assistance

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"Good morninq/afternoon, Disaster Assistance, mv name is

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PAPERWORK BURDEN DISCLOSURE NOTICE FEMA Form 90-69
Public repotting burden for this form 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 the form. you are not required to respond to
this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send comments regarding the
accuracy ofthe 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, Paperwork Reduction Project (1660-0002).
NOTE: Do not send your completed form to this address.

"What state are you calling from?
"Are you able to live in your home?"
"Was your home damaged?"
"Did you have damage to personal property, medical equipment, or an automobile?"
"Was a business that you own or represent affected by the disaster?""
[SERVICE REP: Please check the following information for persons who have already applied or are inquiring about some other type of
assistance.
After asking for the state in which the damage occurred, press F8 or click on the INFO BUTTON on the Tool Bar to determine whether
we are still taking applications for the caller's disaster. If we are still taking applications for this disaster, press the NEW BUl7DN.

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Espahol 1 Fr 1vac.u Fol~cyI Accesjits~llyI Srte Index I Cor~tacZUs

FEMA - P.O. Box 10055 Hyattsville, MD 20762-7055 (800) 621-3362 Fax (800) 827-81 12
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OMB No. 1 660-0002.
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iervice Rep: Please read the following statement to each Delta Call applicant, as they w ~ lnot
l have heard it from the Phone Recorded Message]
Ve are required by law to provide the following Privacy Act Notice to you
?e information you give to FEMA will be used to refer you to disaster assistance programs. It may be shared with other assistance providers to
isure there is no duplication of benefits. It may also be shared with State and local governmental agencies t o help reduce future disaster losses.

~u authorize FEMA and the State to verify the information that we record.
you knowingly make false statements to obtain disaster aid, it is a violation of Federal and State laws."

;ERVICE REP: Click on the CONTINUE BUTTON (or press ALT+C) to complete a application or click on the EXIT BUTTON (or press ALT+::)
le caller is not prepared to apply at this time.]

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Espanol F'rrvacy Fol~cy( Accessih~lfiy( Srte Index ( Contact Us

FEMA - P.O.Box 10055 Hyattsville,MD 20782-7055(800)621-3362Fax (800)827-8112
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[NPSC EMPLOYEES: STOP! ! ! Do not take a registration for DR 139 1 New York. Talk to your supervisor.
DFO personnel follow prearranged instructions.]

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[SERVICE REP: Enter Mr or Ms]

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Power Surgehightning

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Registration 10:91-2481676

MR JOHN J. TESTER

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[SERVICE REP: VERIFY information with the caller for ACCURACY before moving to the next field.]

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"Please give me your Social Security Number."
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Registrant MR JOHN J. TESTER

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Registration ID: 91-2481676

"I am now gang to ask you a series of questions about your drsaster losses They mai, not all appiy but I need to ask aft of them.'

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Registrant: MR JOHN J. TESTER

Registration ID: 91-2481676

"At this time, I need to list all of the vehicles at your home at the time of the disaster. This would include any vehicle owned by you,
your spouse, or one of your dependents regardless of whether or not it was damaged.

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What is the year of the vehicle?"

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Espafiol I Privacy Policy I Accessibility I Sie Index ( Contact Us
FEMA - P 0 Box 10055 Hyattsvtlle,MD 20782-7055 (800) 621-3362 Fax (800) 827-8112

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Registration ID: 91-2481676

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"Did you have any medical expenses as a result of the disaster?" (YesjNo)

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Registrant: MR JOHN J. TESTER

Registration ID: 91-2481676

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"What type(s) of ,nsut%ce coverage do youhave?"

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[Service Rep: IMPORTANT! The default for this field is 'NO RP OR PP INSURANCE' if this field is left blank or if vehicle, medical,
dental, or funeral insurance is listed.]

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FEMA - P 0 Box 10055 Hyattsv~lle,MD 20782-7055 (800) 621-3362 Fax (800) 827-81 12

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Registrant: MR JOHN J. TESTER

Registration ID: 91-2481676

'At this time, I need to list the names of all the persons living in your h o k e at the time of the disaster. This would include any
individuals for whom you are responsible.

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If any other person lived in your home, please spell his or her last name."

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FEMA - P.0 Box 10055 Hyaltsv~lle,MD 20782-7055 (800) 621-3362 Fax (800) 827-8112
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Registration ID: 91-2481676

Registrant: MR JOHN J. TESTER
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"If you were to be eligible for FEMA assistance, would you want FEMA to elect&kally

transfer fundsto your bank account?"

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OMB No. 1660-0002. Em.9-30-200E

:ncv Referrals

Registration ID: 91-2481676

Registrant: MR JOHN J. TESTER

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*iculturalAid
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?tractorsLicense Board
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