Drafted Privacy Act Statement

PRIVACY ACT STATEMENT

AUTHORITY:
National Flood
Act of 1968, Public
the Flood Disaster Protection Act of 1973, Public Law 93-234.

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as amended by

PRINCIPAL PURPOSE(S): This information is being collected for the purpose determining
an applicant's eligibility to request changes to National Flood Insurance Program (NFIP) Flood
Insurance Rate Maps (FIRM).
ROUTINE USE(S): The information on this form may be disclosed as generally permitted
under 5
§ 552a(b) of the Privacy Act 1974, as amended.
DISCLOSURE:
disclosure of information on this form is voluntary; however, failure to
provide the information requested may delay or prevent FEMA from processing a determination
regarding a requested change to a (NFIP) Flood Insurance Rate
(FIRM).