Statement of Voluntary Participation FEMA Form 81-112

O.M.B. No. 1660-0103 Expires June 30, 2008
DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

Statement of Voluntary Participation for
Acquisition of Property for Purpose of Open Space
Fema's Hazard Mitigation Assistance Programs

THIS AGREEMENT is made and entered into this on (date)
, by and between (name of Sub
grantee)
, hereinafter referred to as "Subgrantee," and (property
owner)
, hereinafter referred to as "Seller." The parties agree as follows:
1.

Seller affirms that I/we own the property located at (legal address)
hereinafter referred to as "property."

,

2.

Subgrantee has notified Seller that the Subgrantee may wish to purchase the referenced property,
and, if Seller agrees to sell, Seller must permanently relocate from property.

3.

Subgrantee has identified that the purchase offer valuation of the property as of
(date)
is $
, as determined by appropriate valuation procedures implemented
by Subgrantee and based on FEMA acquisition requirements provided in 44 C.F.R. Part 80, and
relevant program guidance as documented below (e.g., Pre-Disaster Mitigation, Hazard Mitigation
Grant Program, Flood Mitigation Assistance).

4.

Subgrantee has notified the Seller that neither the State nor the Local Government will use its
eminent domain authority to acquire the property for open-space purpose if the Seller chooses
not to participate, or if negotiations fail.

5.

Subgrantee has notified Seller that if the Seller agrees to sell the property to the Subgrantee the transaction is
voluntary and the Seller is not entitled to relocation benefits provided by the Uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970, which are available to property owners who must sell
their properties involuntarily.

6.

Subgrantee affirms that it has provided the notifications and explained the information described in the
preceding paragraphs to the seller, and property identified above is not a part of an intended,
planned, or designated project area where all or substantially all of the property within the area is to be
acquired within specific time limits.

7.

This Agreement shall expire on (date of closing)
Property to the Sub grantee by that date.

, unless Seller has voluntarily sold

Property Owner Signature

Date

Property Owner Signature

Date

Subgrantee's Authorized Agent Signature

Date

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for Property Owners Voluntary Participation Statement is estimated to average 1 hour per response. The burden estimate includes
the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data and completing and submitting the form. You
are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments regarding the accuracy of the
burden estimate 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, and Paperwork Reduction Project (1660-0103). Note: Do not send your
completed form to this address.
FEMA Form 81-112, FEB 08