Form 81-87 A 81-87 A Elevation Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0015
Expires August 31, 2007

ELEVATION FORM

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1.25 hours per resposne. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form.
You are not required to respond to this collection of information unless a vaild OMB control number appears in the upper right corner of this
form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections
Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472,
Paperwork Reduction Project (1660-0015). Submission of the form is required to obtain or retain benefits under the National Flood Insurance
Program. Please do not send your completed survey to the above address.
This form must be completed for request and must be completed and signed by a registered professional engineer or licensed land surveyor. A
DHS-FEMA National Flood Insurance Program (NFIP) Elevation Certificate may be submitted in lieu of this form for single structure
request.
For request to remove a structure on natural grade OR on engineered fill from Special Flood Hazard Area (SFHA), submit the lowest adjecent
grade (the lowest ground touching the structure), including an attached deck or garage. For request to remove an entire parcel of land from the
SFHA, provide the lowest lot elevation; or, if the request involves an area described by metes and bounds, provide the lowest elevation within
the metes and bounds description. In order to process your request, all information on this form must be completed in its entirety. Incomplete
submissions may result in processing delays.
1. NFIP Community Number:

Property Name or Address:

2. Are the elevations listed below based on (check one)
3. What is the elevation datum?

NGVD 29

existing

NAVD 88

or

proposed conditions?

Other (explain)

If any of the elevations listed below were computed using

a datum different than the datum used for the effective Flood Insurance Rate Map (FIRM) (e.g., NGVD 29 or NAVD 88), what was the conversion factor?
Local Elevation +/- ft. = FIRM Datum
4. Please provide the Latitude and Longitude of the most upstream edge of the structure (in decimal degrees):
NAD83
NAD27
Indicate Datum:
.

Lat.

.

Long.

Please provide the Latitude and Longitude of the most upstream edge of the property (in decimal degrees):
NAD27
Indicate Datum:
NAD83

Lat.

.

Long.

.

5. For existing or proposed structures listed below, what are the types of construction? (check all that apply)
crawl space

slab on grade

basement/enclosure

Other (explain)

5. Has DHS - FEMA identified this area as subject to land subsidence or uplift? (See instructions)
If yes, what is the date of the current releveling?

Lot Number

Block
Number

Lowest Lot
Elevation*

/

Lowest
Adjacent
Grade To
Structure

Yes

No

(month/year)

Base Flood
Elevation

B FE
Source

For FEMA Use Only

This certification is to be signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify elevation
information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be
punishable by fine or imprisonment under Ttile 18 of the United States Code, Section 1001.
Certifier's Name:

License Number:

Expiration Date:

Company Name:

Telephone Number:

Fax Number:

Signature:

Date

Seal (optional)
FEMA Form 81-87A, FEB 06

Elevation Form

MT-1 Form 2 Page 1 of 2

Continuation from Page 1.
Lot Number

Block
Number

Lowest Lot
Elevation

Lowest
Adjacent
Grade To
Structure

Base Flood
Elevation

BFE Source

For FEMA Use Only

This cetification is to be signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify elevation
information. All documents submitted in support of this request are correct to the best of knowledge. I understand that any false statement may be punishable by
fine or imprisonment undeer Title 18 of the United States Code, Section 1001.
Certifier's Name:

License Number:

Expiration Date:

Company Name:

Telephone Number:

Fax Number:

Signature:

Date

Seal (optional)

FEMA Form 81-87A,

Elevation Form

MT-1 Form 2 Page 2 of 2