Form FEMA Form 81-65 FEMA Form 81-65 Floodproofing Certificate for Non-Residential Structures

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0008
Expires February 28, 2009

National Flood Insurance Program

FLOODPROOFING CERTIFICATE
FOR NON-RESIDENTIAL STRUCTURES

The floodproofing of non-residential buildings may be permitted as an alternative to elevating to or above the Base Flood Elevation; however, a
floodproofing design certification is required. This form is to be used for that certification. Floodproofing of a residential building does not alter a
community’s floodplain management elevation requirements or affect the insurance rating unless the community has been issued an exception
by FEMA to allow floodproofed residential basements. The permitting of a floodproofed residential basement requires a separate certification
specifying that the design complies with the local floodplain management ordinance.
BUILDING OWNER’S NAME

FOR INSURANCE COMPANY USE

STREET ADDRESS (Including Apt., Unit, Suite, and/or Bldg. Number) OR P.O. ROUTE AND BOX NUMBER

POLICY NUMBER

OTHER DESCRIPTION (Lot and Block Numbers, etc.)

COMPANY NAIC NUMBER

CITY

STATE

ZIP CODE

SECTION I FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
Provide the following from the proper FIRM:

COMMUNITY NUMBER
PANEL NUMBER
SUFFIX
DATE OF FIRM INDEX
FIRM ZONE

BASE FLOOD ELEVATION
(In AO Zones, Use Depth)

SECTION II FLOODPROOFING INFORMATION (By a Registered Professional Engineer or Architect)
Floodproofing Design Elevation Information:
Building is floodproofed to an elevation of ................................... feet NGVD. (Elevation datum used must be the same as that on the FIRM.)
Height of floodproofing on the building above the lowest adjacent grade is ........................................ feet.
(NOTE: For insurance rating purposes, the building’s floodproofed design elevation must be at least one foot above the Base Flood Elevation to receive
rating credit. If the building is floodproofed only to the Base Flood Elevation, then the building’s insurance rating will result in a higher premium.)
SECTION III CERTIFICATION (By Registered Professional Engineer or Architect)
Non-Residential Floodproofed Construction Certification:
I certify that, based upon development and/or review of structural design, specifications, and plans for construction, the design and methods of construction are in accordance with accepted standards of practice for meeting the following provisions:
The structure, together with attendant utilities and sanitary facilities, is watertight to the floodproofed design elevation indicated above, with
walls that are substantially impermeable to the passage of water.
All structural components are capable of resisting hydrostatic and hydrodynamic flood forces, including the effects of buoyancy, and anticipated
debris impact forces.
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.

CERTIFIER’S NAME

LICENSE NUMBER (or Affix Seal)

TITLE

COMPANY NAME

ADDRESS

CITY

STATE

SIGNATURE

DATE

PHONE

ZIP CODE

Copies should be made of this Certificate for: 1) community official, 2) Insurance agent/company, and 3) building owner.

FEMA Form 81-65, Feb 06

Replaces all previous editions

F-056 (2/06)

FLOOD INSURANCE
FLOODPROOFING CERTIFICATE
FEMA FORM 81-65

GENERAL–This information is provided pursuant to Public Law 96-511 (the Paperwork Reduction Act of 1980, as
amended), dated December 11, 1980, to allow the public to participate more fully and meaningfully in the Federal
paperwork review process.
AUTHORITY–Public Law 96-511, amended; 44 U.S.C. 3507; and 5 CFR 1320
PAPERWORK BURDEN DISCLOSURE NOTICE–The public reporting burden for this form is estimated to be 3.25
hours per response. The burden estimates 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, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC
20472, Paperwork Reduction Project (1660-0008).
NOTE: Please do not send your completed form to the above address.