Form FEMA Form 086-0-26 FEMA Form 086-0-26 Elevation Form

O.M.B. No. 1660-0015
Expires February 28, 2014

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
ELEVATION FORM
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 1.63 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, Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell
Street, Arlington, VA 20598-3005 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.
PRIVACY ACT STATEMENT
AUTHORITY: The National Flood Insurance Act of 1968, Public Law 90-448, as amended by the Flood Disaster Protection Act of 1973, Public Law 93-234.
PRINCIPAL PURPOSE(S): This information is being collected for the purpose of 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 U.S.C § 552a(b) of the Privacy Act of 1974, as amended. This includes
using this information as necessary and authorized by the routine uses published in DHS/FEMA/NFIP/LOMA-1 National Flood Insurance Program (NFIP); Letter of Map
Amendment (LOMA) February 15, 2006, 71 FR 7990.
DISCLOSURE: The 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 Maps (FIRM).
This form must be completed for request and must be completed and signed by a registered professional engineer or licensed land surveyor. A FEMA National Flood
Insurance Program (NFIP) Elevation Certificate may be submitted in addition to 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 adjacent 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. All measurements are to be rounded to the nearest tenth of a foot. In order o process your request, all information
on this form must be completed in its entirety. Incomplete submissions will result in processing delays.

Property Name or Address:

1. NFIP Community Number:

existing

2. Are the elevations listed below based on (check one)

or

proposed conditions?

3. For the existing or proposed structures listed below, what are the types of construction? (check all that apply
crawl space
Other (explain)
slab on grade
basement/enclosure
4. Has 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)
NAVD 88
NGVD 29
Other
5. What is the elevation datum?
If any of the elevations listed below were computed using a datum different than that datum used for the effective Flood Insurance Rate Map (FIRM)
(e.g., NGVD 29 or NAVD 88), what was the conversion factor?
6a. Please provide the Latitude and Longitude of the most upstream edge of the structure (in decimal degree to the nearest fifth decimal place)
Indicate Datum
NAD83
NAD27
WGS84
Lat.
Long.
6b. Please provide the Latitude and Longitude of the most upstream edge of the property (in decimal degree to the nearest fifth decimal place)
NAD27
NAD83
WGS84
Indicate Datum
Lat.
Long.
Address

Lot
Number

Block Number

Lowest Adjacent
Lowest
Lot Elevation 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 Tile 18 of the United States Code, Section 1001.
Certifier's Name:

License Number:

Company Name:

Telephone Number:

E-mail:

Fax Number:

Signature:

Date

FEMA Form 086-0-26A, (2/2011)

Elevation Form

Expiration Date:

Seal (optional)
MT-1 Form 2 Page 1 of 2

Continuation from Page 1.
Address

Lot
Number

Block Number

Lowest
Adjacent
Grade To
Structure

Lowest
Lot Elevation

Certifier's Name:

License Number:

Company Name:

Telephone Number:

E-mail:

Fax Number:

Signature:

Date

Base Flood
Elevation

BFE Source

Expiration Date:

Seal (optional)

FEMA Form 086-0-26A, (2/2011)

Elevation Form

MT-1 Form 2 Page 2 of 2