Form 81-64 Application for Participation in the National Flood Insu

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0004
Expires February 29, 2008

APPLICATION FOR PARTICIPATION IN THE NATIONAL FLOOD
INSURANCE PROGRAM
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 4 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing, and submitting the form. You are not required to submit to this collection of information unless it
displays a valid OMB control number. Send comments regarding the accuracy of the burden estinmate and any suggestions for reducing the burden to: Information
Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street SW, Washington, DC 20472, Paperwork Reduction
Project (1660-0004). NOTE: Do not send your completed form to this address.
1. APPLICANT COMMUNITY NAME (City, town, etc.)

DATE

COUNTY, STATE

2. COMMUNITY OFFICIAL - CHIEF EXECUTIVE OFFICER (CEO)

E-MAIL ADDRESS

TELEPHONE NO. (Include area code)

E-MAIL ADDRESS

TELEPHONE NO. (Include area code)

ADDRESS (Street or box no. city, state, zip code)

3. PROGRAM COORDINATOR (Official, if different from above, with overall
responsibility for implementing program)

ADDRESS (Street or box no., city, state, zip code)

LOCATION OF COMMUNITY REPOSITORY FOR PUBLIC INSPECTION OF NFIP MAPS

ADDRESS

5. ESTIMATES FOR THOSE AREAS PRONE TO FLOOD AND/OR MUDSLIDE AS OF THE DATE OF THIS APPLICATION
AREA IN ACRES

NO. OF 1-4
FAMILYSTRUCTURES

POPULATION

NO. OF ALL
OTHER STRUCTURES

6. ESTIMATES OF TOTALS IN ENTIRE COMMUNITY
NO. OF 1-4
FAMILYSTRUCTURES

POPULATION

NO. OF ALL
OTHER STRUCTURES

7. FOR FEMA REGIONAL USE ONLY
1. FEMA REGIONAL OFFICE

2. NAME OF CONTACT

3. TELEPHONE NO.

4. LEVEL OF 44 CFR 60.3 REGULATION ADOPTED (Check one)
60.3

60.3(b)

60.3(c)

5. CHECK APPROPRIATE BOX:
60.3(d)

60.3(e)

EMERGENCY PHASE

REGULAR PHASE

IF REGULAR PROGRAM, SPECIFY FIRM INDEX DATE. IF USING ANOTHER COMMUNITY'S FIRM, GIVE COMMUNITY NAME, CID, FIRM INDEX DATE AND MAP
PANEL NUMBER DEPICTING COMMUNITY

FEMA Form 81-64, APR 06