U.S. DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY ELEVATION FORM O.M.B. NO. 1660-0015 Expires December 31, 2010 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. 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 0 existing or 0 proposed conditions? (Check one) 3. What is the elevation datum? 0 NGVD 29 0 NAVD 88 0 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): Indicate Datum: 0 NAD83 0 NAD27 . Lat. . Long. Please provide the Latitude and Longitude of the most upstream edge of the property (in decimal degrees): Indicate Datum: 0 NAD83 0 NAD27 . Lat. . Long. 5. For the existing or proposed structures listed below, what are the types of construction? (check all that apply) 0 crawl space 0 slab on grade 0 basement/enclosure 0 other (explain) 6. Has DHS - FEMA identified this area as subject to land subsidence or uplift? (see instructions) 0 Yes 0 No If yes, what is the date of the current releveling? / (month/year) 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: Continued from Page 1. 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: DHS - FEMA Form 81-87A, DEC 07 Elevation Form MT-1 Form 2 Page 2 of 2 DHS - FEMA Form 81-87A, DEC 07 Elevation Form MT-1 Form 2 Page 1 of 2