Form FF-81-92 Application Form (English Version)

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US. DEPARTLENTOF HOMELAND SECUHTY FEDERAL BIERGENCY m E M E H T AOENCY

APPLICATION FORM FOR SINGLE RESIDENIAL LOT OR STRUCTURE AIIRENDMENTS TO
NATlONAL ROOD INSURANCE PROGRAM MAPS

NO. 1618-901,

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PAPERWORK REDUCTION ACT
Rlbllc r e p d n g burden for W s form Is edlmated to average 2A houa per naponso. Tho budon d m & , k n l u d r tho t h o for nvlewlng
Instructlms, soarching oxlrting d&a sources, gathedng and malntalningthe modod dsdq and complrtlng, r w l d n g , n d wbmlttlngtho
tom. Y w pro not nqrlred to rwpond to this cdlodlon dWormdon uniess a valld OMB conbd numbor Is dlsplayod Intho r q p r rlght
comor of thla form. Sond comments regardng the acwncy dtho burden eatlmato and any argpdlonr for rodudngthls budon to:
lnfotmsdlon Cdlodiona Managem&, US. [kparbnont of HomelandSewrlty, Federal Emorgsncy ManagemotAgency, 500 C Stroot S.W.,
Washlngbon DC 2U72, Pspemork Ro&dlon ProJoct( 1 6 6 U m . Slbmlaslon d t h l s form Is reqrlred to obtaln or retdn bomflts mder the
Nationd Flood lnsuance Progun.
This form s h d d k used to nqwctthatthr Fodoral Emergency Mamgement Agency (FEMA) remove a rhglo structuo or legally recordod
pwcel of land or portlorn thored, drcribed by motes a d bounds, ce~tiflodby a nglatered profrrlonal onglnew a Ilcenaodland surwyor,
from a dwlg~sdedSpoclal Flood m
d Area (SFWQ, an area that would be Inmdated by- flood havlng a 19khanco of M n g qualed or
excoedod In uy glven )nu(bar, flood), vla l.&rdMap Amendment (LOMA). It Wl not k
f a r q w d s submltbd by dovdopn, far
requosts lnwlving mrltlplo rtructur or lots, for propow In alllnlal fan proas a coastal hlgh hazard mu (V m@,
or requosta Inwlvlng
tho d a m m e t dflll. (NOTE: b e MT-1forms for such reauestd. RIIs ddned u mrterlal laced to nlao tho ma& to or above tho Bas,
I~ l & dElovation fBm: Tho canmon condnwtlon ~ractl#of reinovlna mrrlteble exl.tina mabrlal I h s d l l a;d bacldllllna vdth reloci
struchrnl mate& la hot consldored tho p l a a m o i offlll #the pradcidoos n d dtertho Zxldlng (*rd
g k o ) olevatlo{whlch Is at or
above the B E . Alw, fib that Is @ x e dkforo tho dab oftho nrat Natlonal Flood Inaumce P r o-u r n WlP)
.
. map
. howlng h#m a In an SFHA

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A Ietbr from DHS - FEMA stating that Medstlngstrucbur a pared of lrnd that hpr not boon
LOMA:
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A -This sectlon may be canplotad by tho property amur a bythe property wvnr's agent

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Has fill been plaad on y o u prop-

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NO

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- yes - ryes, STOR!

-YOU must complete the MT-1
appllc.tlon
forms; vidt
.~ ~ l l m m r v . h ~ ~ ~ mot - v1 . m ~ d l
or call tho FEMA Map Aarldamo Center to! frw: (877+EMA MAP) (877336-

2.

Logal doacrlp4lon of Proprty (Lot, Block, Subdvldon) and street address oftho Property
(KdMoret from malllng adchat):

3.

Are you requestingthat tho flood m e dwlgndon be romwedfrm (check on$:
Y o u d r e logally rocordod property7
A portlon of your legally recorded propfly? (a mobs and bomdr d e d p t l o n and map ofthe are8 to k removed,
artifled bya roglrtend profordand endnew or Ucemd land W N V r an reqrlred)
A struetwo on your property7 What Is tho dat. dcondnwtlon?

All documents s u b m ~ In
d support d t h l s requost are correct to tho b w t dmy knwrledg.. Imderatandthat my Mae sMmentmay ba
pmlshablo by flne or Imprlroment m d w Title 18 oftho U n i ~ d Codo,
~ s SeetlonlWl.
Appllca&'s Nome:

Company.

Malling Addross:

Daytlmo Telephone No.:

E-mall adchss:

Fax Na:

fignabre of Appllcat (nqulre4

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a DEC06

W S FEMA Form81

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B - m a sectloo nust be completed by. reglstend pohaslond en~lneerw Lensed I dsurveyor.

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NOTE: If nNFlP Eev&lon Certiflat. h u inady bwn completed f a thh propow, It may be w b n i t b d h addltlm t o 01s form.

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The regulations pertdning to LOMAs are presented in the National Flood Insurance R q r a m (NRP) regulations under Title44, Chapter I, Parts 70 and
72. Cocb of Federd Reglaions. The purpose d Part 70 is to provide an administrative procedure whereby DHS FEMA MI review infamaion
submitted by an cwner a lessee of poperty who beleres that his or her property has been inadvertently included In a Wgnated SFHA. The necessity
of Part 70 is due in part to the technical d i i u l t y of accurziely delineatingthe SFHA boundary on m NRP map. Part 70 procedures shall not apply if the
topcpraphy has been altered since the effective dae of the first NFlP map [e.g.. a Flood Insurance Rate Map (FIRM) or Flood Hazard Boundary ME^
(FHBM)] showing the poperty to bewithln the SFHA

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DHS- FEMA's detembaion as to whether a structure or legalb recorded parcel d land, or portions thered, described by metes and bounds, ma/ be
remwed from the SFHA will be based upon a comparison of the Base (I%mnud-chmce) Flood Elwation (WE) with certain elwation informlon. For
Zone A, wth no B E determined, rder to Meneghg Fboalein bvebpment m &proxjmete Zone A Areas, A Guide lor Wahhg and d e b p i n o Base
(IO(rYe8f) Flood Ekvdions. The elevation Informaion required is dependent on whether a sbucture, or a legally recorded parcel of land, is to be
removedfrom the SFHA.

Item to bo Removed from the SMA: (chrck one)

Elevation Mormatlon Rqulred: (completm Item 6)
Lowest AdJacent Grade to the structure (me elevaion of the lowest
g w n d touching the structure including attached deck cr garage)

Strudure locaed on natural made (LOMA)

Elevation d the lowest g a n d on the parcel a withm the portion of land

Undweloped legdb recorded parcel d l m d (LOMA)
1. What is the m e of construction? (checkone)

to be r e m e d f i a n the SFHA (skip to I t m 2)

uavl space

Cl slab on gade

Cl bcsementlenclosure

other (expldn)
2. BUWNG INFORMATION
Building Street Ackiress (including Apt. Unit. Suite, mdlor Bldg. No.):

Roperty Description (Lot and Block Numb'&. Tax Parcel Number. Legal Description, stc.):

3. GEOGRAPHIC COOfWNATE DATA
Rease provide the Laitude and Longtude d the most upsirearn edge d the structure (in decimal degrees)
InacateD a m :
NADB3 O NAD27
Rease provide the Laitude and Longtuded the most upsbeam edge d the property (in decimd degees)
lrdlcateD a r n
NAD83
NAD27

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Let.

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Long.

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Ld.

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Long.

4. FLOOD INSURANCE RATE MAP (FIRM) I N O M T I O N

NFlP Community Number:

Base Flood Elevation (BFE):

Map &Panel Number:
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Source d BFE
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6. BWATION INFORMATION(SURVEY REQURED)
Lowest AQacentGrade (LAG) to the structure
ft. (m)
Elevdion of the lowest grade on the poperty; or, mstes and bands area
.
ft. (m)
Indicatethe a m (md datum cowenion if different from NGVD 29 or NAVD 88)
NGW 29
NAW 88 Other (Descdbe):
Has FEMA identifiedthis area as subject to l a d subsidence or upliM
Yes
No
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If Yes, what is the date of the current relevding?
This certification is to be signed and seded by a licensed land survyor, registered professional en#neer. or archlect authorized by law to certify
elevaion information. All doa~mentssubmitted in support of this rewest are correct to the best of my knovrledge. I understandthat any false statement
may be punishableby fine or imprisonment under Title 18 of the Unled States Code, Sedion l w l .
License No.:

Certifier's Name:
Compmy Nme:

Expiration Date:
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Telephone No.:

Fen No.:

Sed (optional)

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(See attached'address listing for LOMAs)
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DHS FEMA Form 81

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M T U Form

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OHS R M A Form 8142, DECOb

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