Old form with changes

U.S. DEPARTMENT OF HOMELAND SECURITY - Federal Emergency Management Agency ELEVATION FORM

O.M.B. NO. 1660-0015 Expires December 31, 20102013

PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 1.25 hours per response. 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 valid 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, U.S. 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 requests 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 requests. For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area (SFHA), submit the lowest adjacent grade (the lowest ground touching the structure), including an attached deck or garage. For requests 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. All measurements are to be rounded to nearest tenth of a foot. In order to process your request, all information on this form must be completed in its entirety. Incomplete submissions maywill result in processing delays.
1. NFIP Community Number:            Property Name or Address:            2. Are the elevations listed below based on existing or proposed conditions? (Check one) 3. For the 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) 4. Has DHS - FEMA identified this area as subject to land subsidence or uplift? (see instructions) Yes No If yes, what is the date of the current re-leveling?      /     (month/year) 5. What is the elevation datum? NGVD 29 NAVD 88 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 4.6. Please provide the Latitude and Longitude of the most upstream edge of the structure (in decimal degrees to the nearest fifth decimal place): Indicate Datum: NAD83WGS84 NAD83 NAD27 . Lat. .     .         Long.    .        Please provide the Latitude and Longitude of the most upstream edge of the property (in decimal degrees to the nearest fifth decimal place): Indicate Datum: NAD83WGS84 NAD83 NAD27 . Lat. .     .         Long. 5. For the 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)       6. Has DHS - FEMA identified this area as subject to land subsidence or uplift? (see instructions) Yes No If yes, what is the date of the current releveling?      /     (month/year) .    .
Lot NumberAddress	Block Lot Number	Lowest Lot Elevation*Block Number		Lowest Adjacent Grade To StructureLot Elevation*	Base Flood ElevationLowest Adjacent Grade To Structure	BFE SourceBase Flood Elevation		For DHS - FEMA Use OnlyBFE Source
     	     	     		     	     	     
     	     	     		     	     	     
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 Title 18 of the United States Code, Section 1001.
Certifier’s Name:			License No.:				Expiration Date:
Company Name:			Telephone No.:
Email:			Fax No.				Seal (optional)
Signature:			Date:

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Address	Lot Number	Block Number		Lowest Lot Elevation*	Lowest Adjacent Grade To Structure	Base Flood Elevation		BFE Source
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 Title 18 of the United States Code, Section 1001.
Certifier’s Name:      			License No.:      				Expiration Date:      
Company Name:      			Telephone No.:      				Fax No.:      
Email:			Fax No.				Seal (optional)
Signature:			Date:      
Seal (optional) *For requests involving a portion of property, include the lowest ground elevation within the metes and bounds description. Please note: If the Lowest Adjacent Grade to Structure is the only elevation provided, a determination will be issued for the structure only.

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Lot Number	Block Number	Lowest Lot Elevation	Lowest Adjacent Grade To Structure		Base Flood Elevation	BFE Source		For DHS - 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 Title 18 of the United States Code, Section 1001.
Certifier’s Name:      				License No.:      			Expiration Date:      
Company Name:      				Telephone No.:      			Fax No.:      
Signature:				Date:      
Seal (optional)

DHS - FEMA Form 81-87A, DEC 0710 Elevation Form MT-1 Form 2 Page 1 of 2