U.S. DEPARTMENT OF HOMELAND SECURITY	ELEVATION CERTIFICATE

Federal Emergency Management Agency

National Flood Insurance Program	Important: Read the instructions on pages 1-9.

SECTION A - PROPERTY INFORMATION	For Insurance Company Use:
A1.	Building Owner’s Name	Policy Number
A2.	Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.

Company NAIC Number
City	State ZIP Code
A3.	Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.)

A4.	Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.)

A5.	Latitude/Longitude: Lat. Long.	Horizontal Datum:	NAD 1927	NAD 1983

A6.	Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.

A7.	Building Diagram Number

A8.	For a building with a crawlspace or enclosure(s):	A9.	For a building with an attached garage:

a)	Square footage of crawlspace or enclosure(s)	sq ft	a)	Square footage of attached garage	sq ft

b)	No. of permanent flood openings in the crawlspace or	b)	No. of permanent flood openings in the attached garage

enclosure(s) within 1.0 foot above adjacent grade	within 1.0 foot above adjacent grade

c)	Total net area of flood openings in A8.b	sq in	c)	Total net area of flood openings in A9.b	sq in

d)	Engineered flood openings?	Yes	No	d)	Engineered flood openings?	Yes	No

SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION

B1. NFIP Community Name & Community Number

B2. County Name

B3. State

B4. Map/Panel Number

B5. Suffix

B6. FIRM Index Date

B7. FIRM Panel Effective/Revised Date

B8. Flood Zone(s)

B9. Base Flood Elevation(s) (Zone AO, use base flood depth)

B10.	Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9.

FIS Profile	FIRM	Community Determined	Other (Describe)

B11.	Indicate elevation datum used for BFE in Item B9:	NGVD 1929	NAVD 1988	Other (Describe)

B12.	Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)?	Yes	No

Designation Date	CBRS	OPA

SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED)

C1.	Building elevations are based on:	Construction Drawings*	Building Under Construction*	Finished Construction

*A new Elevation Certificate will be required when construction of the building is complete.

C2.	Elevations – Zones A1-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/A1-A30, AR/AH, AR/AO. Complete Items C2.a-h below according to the building diagram specified in Item A7. Use the same datum as the BFE.

Benchmark Utilized Vertical Datum

Conversion/Comments

Check the measurement used.

a)	Top of bottom floor (including basement, crawlspace, or enclosure floor) .	feet	meters (Puerto Rico only)

b)	Top of the next higher floor	.	feet	meters (Puerto Rico only)

c)	Bottom of the lowest horizontal structural member (V Zones only)	.	feet	meters (Puerto Rico only)

d)	Attached garage (top of slab)	.	feet	meters (Puerto Rico only)

e)	Lowest elevation of machinery or equipment servicing the building	.	feet	meters (Puerto Rico only)

(Describe type of equipment and location in Comments)

f)	Lowest adjacent (finished) grade next to building (LAG)	.	feet	meters (Puerto Rico only)

g)	Highest adjacent (finished) grade next to building (HAG)	.	feet	meters (Puerto Rico only)

h)	Lowest adjacent grade at lowest elevation of deck or stairs, including	.	feet	meters (Puerto Rico only)

structural support

SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. I certify that the information on this Certificate represents my best efforts to interpret the data available.

I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.

Check here if comments are provided on back of form.	Were latitude and longitude in Section A provided by a

licensed land surveyor?	Yes	No
Certifier’s Name	License Number

Title	Company Name
Address	City	State	ZIP Code
Signature	Date	Telephone

IMPORTANT: In these spaces, copy the corresponding information from Section A.	For Insurance Company Use:
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.

Policy Number
City State ZIP Code	Company NAIC Number
SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED)
Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner.
Comments
Signature	Date

Check here if attachments
SECTION E - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE)

For Zones AO and A (without BFE), complete Items E1-E5. If the Certificate is intended to support a LOMA or LOMR-F request, complete Sections A, B,

and C. For Items E1-E4, use natural grade, if available. Check the measurement used. In Puerto Rico only, enter meters.

E1.	Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG).

a) Top of bottom floor (including basement, crawlspace, or enclosure) is . feet meters above or below the HAG.

b) Top of bottom floor (including basement, crawlspace, or enclosure) is . feet meters above or below the LAG.

E2.	For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9 (see pages 8-9 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is . feet meters above or below the HAG.

E3.	Attached garage (top of slab) is . feet meters above or below the HAG.

E4.	Top of platform of machinery and/or equipment servicing the building is . feet meters above or below the HAG.

E5.	Zone AO only: If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community’s floodplain management ordinance? Yes No Unknown. The local official must certify this information in Section G.
SECTION F - PROPERTY OWNER (OR OWNER’S REPRESENTATIVE) CERTIFICATION
The property owner or owner’s authorized representative who completes Sections A, B, and E for Zone A (without a FEMA-issued or community-issued BFE) or Zone AO must sign here. The statements in Sections A, B, and E are correct to the best of my knowledge.
Property Owner’s or Owner’s Authorized Representative’s Name

Address	City	State	ZIP Code

Signature	Date	Telephone
Comments

Check here if attachments

SECTION G - COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community’s floodplain management ordinance can complete Sections A, B, C (or E), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8 and G9.

G1.	The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.)

G2.	A community official completed Section E for a building located in Zone A (without a FEMA-issued or community-issued BFE) or Zone AO.

G3.	The following information (Items G4-G9) is provided for community floodplain management purposes.

G4. Permit Number

G5. Date Permit Issued

G6. Date Certificate Of Compliance/Occupancy Issued

G7. This permit has been issued for:	New Construction	Substantial Improvement

G8. Elevation of as-built lowest floor (including basement) of the building: . feet meters (PR) Datum

G9. BFE or (in Zone AO) depth of flooding at the building site:	. feet meters (PR) Datum

G10. Community’s design flood elevation	. feet meters (PR) Datum

Local Official’s Name	Title
Community Name	Telephone
Signature	Date
Comments

Check here if attachments

Building Photographs

See Instructions for Item A6.

For Insurance Company Use:
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.

Policy Number
City State ZIP Code

Company NAIC Number

If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to the instructions for Item A6. Identify all photographs with: date taken; “Front View” and “Rear View”; and, if required, “Right Side View” and “Left Side View.” If submitting more photographs than will fit on this page, use the Continuation Page on the reverse.

Building Photographs

Continuation Page

For Insurance Company Use:
Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No.

Policy Number
City State ZIP Code

Company NAIC Number

If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs with: date taken; “Front View” and “Rear View”; and, if required, “Right Side View” and “Left Side View.”

FEMA Form 81-31, Mar 09	See reverse side for continuation.	Replaces all previous editions

FEMA Form 81-31, January 2003	See reverse side for continuation.	Replaces all previous editions

FEMA Form 81-31, Mar 09	Replaces all previous editions

Instructions – Page 2

PLACE

SEAL

HERE

OMB No. 1660-0008

Expires March 31, 2012

ELEVATION CERTIFICATE

Greenbelt

2009-04-15

bspriggs

Greenhorne and O'Mara, Inc.