Form FEMA Form 086-0-2 FEMA Form 086-0-2 Flood Insurance Cancellation / Nullification Request

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program

O.M.B. No. 1660-0006 Expires August 31, 2012
CURRENT POLICY NUMBER

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM
IF THIS POLICY IS CANCELED BY THE INSURED THROUGH HIS OR HER AUTHORIZED REPRESENTATIVE, IT SHALL REMAIN IN FORCE FOR THE BENEFIT OF THE MOR TGAGEE (OR TRUSTEE)
F O R 3 0 D AY S A F T E R W R I T T E N N O T I C E T O T H E M O R T G A G E E ( O R T R U S T E E ) O F S U C H C A N C E L L AT I O N A N D T H E N C E A S E . S E E R E V E R S E S I D E F O R P R I V A C Y S TAT E M E N T .

CANCELLATION EFFECTIVE DATE _____ / _____ / _______

POLICY TERM IS FROM _____ / _____ / _______ TO _____ / _____ / _______
DD

YYYY

MM

DD

MM

YYYY

MAILING ADDRESS, PHONE NO., AND FAX NO. OF LICENSED PROPERTY OR
CASUALTY INSURANCE AGENT/BROKER WHOSE POLICY IS BEING TERMINATED

INSURED
MAILING ADDRESS

MM

DD

YYYY

NAME, ADDRESS, AND PHONE NO., OF INSURED FOR MAILING REFUND

LIST OTHER PARTIES NOTIFIED

NAME, ADDRESS, PHONE NO., AND FAX NO. OF FIRST MORTGAGEE INCLUDING
LOAN NUMBER
OTHER
PARTIES NOTIFIED

FIRST
MORTGAGEE

AGENT
INFORMATION

POLICY
TERM

IMPORTANT—PLEASE PRINT OR TYPE

LOAN NUMBER: ___________________________

PROPERTY
LOCATION

INSURED PROPERTY LOCATION

CANCELLATION REASON CODE

THIS POLICY MAY ONLY BE CANCELED UPON TERMINATION OF THE INSURED’S
OWNERSHIP IN THE PROPERTY COVERED AT THE LOCATION DESCRIBED ON THE
DECLARATION PAGE OF THE POLICY FOR REASON CODES (1) AND (2) BELOW.

REFUND

C ANCELLATION REASON CODE: __________

1) BUILDING SOLD OR REMOVED

13) VOIDANCE PRIOR TO EFFECTIVE DATE

2)

CONTENTS SOLD OR REMOVED

14) VOIDANCE DUE TO CREDIT CARD ERROR

3)

POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON EXPIRATION
DATE WITH OTHER INSURANCE COVERAGE

15) INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

4) DUPLICATE NFIP POLICIES

16) DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP

5) NON-PAYMENT

18) MORTGAGE PAID OFF ON MPPP POLICY

6) RISK NOT ELIGIBLE FOR COVERAGE

19) INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR

7) PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

C
O
P
Y

20) POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE
LOSS PROPERTY)

8) POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED BY
MORTGAGEE AS PROPERTY NOT IN SFHA

21) OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

9) INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

SIGNATURE

N
F
I
P

22) CANCEL/REWRITE DUE TO MISRATING

10) CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP

23) FRAUD (FEMA APPROVAL REQUIRED)

12) MORTGAGE PAID OFF

24) CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 OR AT REQUEST OF INSURED)

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT MAY BE PUNISHABLE BY FINE OR IMPRISONMENT
UNDER 18 U.S. CODE, SECTION 1001. INSURANCE AGENT ALSO CERTIFIES THAT ITEMS ON THE REVERSE HAVE BEEN DISCUSSED WITH INSURED.
_________________________________________
SIGNATURE OF INSURED

(NOT REQUIRED FOR REASON 5, 6, OR 22)

FEMA Form 086-0-2, AUG 09

_____ / _____ / _______
MM

DD

YYYY

_________________________________________
SIGNATURE OF AGENT/BROKER

_____ / _____ / _______
MM

DD

YYYY

AGENT/BROKER TAX ID _________________________________________________________

Previously FEMA Form 81-17

F-052 (8/09)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT: SEND ORIGINAL TO NFIP, KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO THE INSURED, AND FOURTH COPY TO MORTGAGEE.

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program

O.M.B. No. 1660-0006 Expires August 31, 2012
CURRENT POLICY NUMBER

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM
IF THIS POLICY IS CANCELED BY THE INSURED THROUGH HIS OR HER AUTHORIZED REPRESENTATIVE, IT SHALL REMAIN IN FORCE FOR THE BENEFIT OF THE MOR TGAGEE (OR TRUSTEE)
F O R 3 0 D AY S A F T E R W R I T T E N N O T I C E T O T H E M O R T G A G E E ( O R T R U S T E E ) O F S U C H C A N C E L L AT I O N A N D T H E N C E A S E . S E E R E V E R S E S I D E F O R P R I V A C Y S TAT E M E N T .

CANCELLATION EFFECTIVE DATE _____ / _____ / _______

POLICY TERM IS FROM _____ / _____ / _______ TO _____ / _____ / _______
DD

YYYY

MM

DD

MM

YYYY

MAILING ADDRESS, PHONE NO., AND FAX NO. OF LICENSED PROPERTY OR
CASUALTY INSURANCE AGENT/BROKER WHOSE POLICY IS BEING TERMINATED

INSURED
MAILING ADDRESS

MM

DD

YYYY

NAME, ADDRESS, AND PHONE NO., OF INSURED FOR MAILING REFUND

LIST OTHER PARTIES NOTIFIED

NAME, ADDRESS, PHONE NO., AND FAX NO. OF FIRST MORTGAGEE INCLUDING
LOAN NUMBER
OTHER
PARTIES NOTIFIED

FIRST
MORTGAGEE

AGENT
INFORMATION

POLICY
TERM

IMPORTANT—PLEASE PRINT OR TYPE

LOAN NUMBER: ___________________________

PROPERTY
LOCATION

INSURED PROPERTY LOCATION

CANCELLATION REASON CODE

THIS POLICY MAY ONLY BE CANCELED UPON TERMINATION OF THE INSURED’S
OWNERSHIP IN THE PROPERTY COVERED AT THE LOCATION DESCRIBED ON THE
DECLARATION PAGE OF THE POLICY FOR REASON CODES (1) AND (2) BELOW.

REFUND

C ANCELLATION REASON CODE: __________

1) BUILDING SOLD OR REMOVED

13) VOIDANCE PRIOR TO EFFECTIVE DATE

2)

CONTENTS SOLD OR REMOVED

14) VOIDANCE DUE TO CREDIT CARD ERROR

3)

POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON EXPIRATION
DATE WITH OTHER INSURANCE COVERAGE

15) INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

4) DUPLICATE NFIP POLICIES

16) DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP

5) NON-PAYMENT

18) MORTGAGE PAID OFF ON MPPP POLICY

6) RISK NOT ELIGIBLE FOR COVERAGE

19) INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR

7) PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

C
O
P
Y

20) POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE
LOSS PROPERTY)

8) POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED BY
MORTGAGEE AS PROPERTY NOT IN SFHA

21) OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

9) INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

SIGNATURE

A
G
E
N
T

22) CANCEL/REWRITE DUE TO MISRATING

10) CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP

23) FRAUD (FEMA APPROVAL REQUIRED)

12) MORTGAGE PAID OFF

24) CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 OR AT REQUEST OF INSURED)

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT MAY BE PUNISHABLE BY FINE OR IMPRISONMENT
UNDER 18 U.S. CODE, SECTION 1001. INSURANCE AGENT ALSO CERTIFIES THAT ITEMS ON THE REVERSE HAVE BEEN DISCUSSED WITH INSURED.
_________________________________________
SIGNATURE OF INSURED

(NOT REQUIRED FOR REASON 5, 6, OR 22)

FEMA Form 086-0-2, AUG 09

_____ / _____ / _______
MM

DD

YYYY

_________________________________________
SIGNATURE OF AGENT/BROKER

_____ / _____ / _______
MM

DD

YYYY

AGENT/BROKER TAX ID _________________________________________________________

Previously FEMA Form 81-17

F-052 (8/09)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT: SEND ORIGINAL TO NFIP, KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO THE INSURED, AND FOURTH COPY TO MORTGAGEE.

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program

O.M.B. No. 1660-0006 Expires August 31, 2012
CURRENT POLICY NUMBER

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM
IF THIS POLICY IS CANCELED BY THE INSURED THROUGH HIS OR HER AUTHORIZED REPRESENTATIVE, IT SHALL REMAIN IN FORCE FOR THE BENEFIT OF THE MOR TGAGEE (OR TRUSTEE)
F O R 3 0 D AY S A F T E R W R I T T E N N O T I C E T O T H E M O R T G A G E E ( O R T R U S T E E ) O F S U C H C A N C E L L AT I O N A N D T H E N C E A S E . S E E R E V E R S E S I D E F O R P R I V A C Y S TAT E M E N T .

CANCELLATION EFFECTIVE DATE _____ / _____ / _______

POLICY TERM IS FROM _____ / _____ / _______ TO _____ / _____ / _______
DD

YYYY

MM

DD

MM

YYYY

MAILING ADDRESS, PHONE NO., AND FAX NO. OF LICENSED PROPERTY OR
CASUALTY INSURANCE AGENT/BROKER WHOSE POLICY IS BEING TERMINATED

INSURED
MAILING ADDRESS

MM

DD

YYYY

NAME, ADDRESS, AND PHONE NO., OF INSURED FOR MAILING REFUND

LIST OTHER PARTIES NOTIFIED

NAME, ADDRESS, PHONE NO., AND FAX NO. OF FIRST MORTGAGEE INCLUDING
LOAN NUMBER
OTHER
PARTIES NOTIFIED

FIRST
MORTGAGEE

AGENT
INFORMATION

POLICY
TERM

IMPORTANT—PLEASE PRINT OR TYPE

LOAN NUMBER: ___________________________

PROPERTY
LOCATION

INSURED PROPERTY LOCATION

CANCELLATION REASON CODE

THIS POLICY MAY ONLY BE CANCELED UPON TERMINATION OF THE INSURED’S
OWNERSHIP IN THE PROPERTY COVERED AT THE LOCATION DESCRIBED ON THE
DECLARATION PAGE OF THE POLICY FOR REASON CODES (1) AND (2) BELOW.

13) VOIDANCE PRIOR TO EFFECTIVE DATE

2)

CONTENTS SOLD OR REMOVED

14) VOIDANCE DUE TO CREDIT CARD ERROR

3)

POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON EXPIRATION
DATE WITH OTHER INSURANCE COVERAGE

15) INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

4) DUPLICATE NFIP POLICIES

16) DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP

5) NON-PAYMENT

18) MORTGAGE PAID OFF ON MPPP POLICY

6) RISK NOT ELIGIBLE FOR COVERAGE

19) INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR

REFUND

C
O
P
Y

20) POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE
LOSS PROPERTY)

8) POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED BY
MORTGAGEE AS PROPERTY NOT IN SFHA

21) OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

9) INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

SIGNATURE

C ANCELLATION REASON CODE: __________

1) BUILDING SOLD OR REMOVED

7) PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

I
N
S
U
R
E
D

22) CANCEL/REWRITE DUE TO MISRATING

10) CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP

23) FRAUD (FEMA APPROVAL REQUIRED)

12) MORTGAGE PAID OFF

24) CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 OR AT REQUEST OF INSURED)

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT MAY BE PUNISHABLE BY FINE OR IMPRISONMENT
UNDER 18 U.S. CODE, SECTION 1001. INSURANCE AGENT ALSO CERTIFIES THAT ITEMS ON THE REVERSE HAVE BEEN DISCUSSED WITH INSURED.
_________________________________________
SIGNATURE OF INSURED

(NOT REQUIRED FOR REASON 5, 6, OR 22)

FEMA Form 086-0-2, AUG 09

_____ / _____ / _______
MM

DD

YYYY

_________________________________________
SIGNATURE OF AGENT/BROKER

_____ / _____ / _______
MM

DD

YYYY

AGENT/BROKER TAX ID _________________________________________________________

Previously FEMA Form 81-17

F-052 (8/09)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT: SEND ORIGINAL TO NFIP, KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO THE INSURED, AND FOURTH COPY TO MORTGAGEE.

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program

O.M.B. No. 1660-0006 Expires August 31, 2012
CURRENT POLICY NUMBER

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM
IF THIS POLICY IS CANCELED BY THE INSURED THROUGH HIS OR HER AUTHORIZED REPRESENTATIVE, IT SHALL REMAIN IN FORCE FOR THE BENEFIT OF THE MOR TGAGEE (OR TRUSTEE)
F O R 3 0 D AY S A F T E R W R I T T E N N O T I C E T O T H E M O R T G A G E E ( O R T R U S T E E ) O F S U C H C A N C E L L AT I O N A N D T H E N C E A S E . S E E R E V E R S E S I D E F O R P R I V A C Y S TAT E M E N T .

CANCELLATION EFFECTIVE DATE _____ / _____ / _______

POLICY TERM IS FROM _____ / _____ / _______ TO _____ / _____ / _______
DD

YYYY

MM

DD

MM

YYYY

MAILING ADDRESS, PHONE NO., AND FAX NO. OF LICENSED PROPERTY OR
CASUALTY INSURANCE AGENT/BROKER WHOSE POLICY IS BEING TERMINATED

INSURED
MAILING ADDRESS

MM

DD

YYYY

NAME, ADDRESS, AND PHONE NO., OF INSURED FOR MAILING REFUND

M
O
R
T
G
A
G
E
E

LIST OTHER PARTIES NOTIFIED

NAME, ADDRESS, PHONE NO., AND FAX NO. OF FIRST MORTGAGEE INCLUDING
LOAN NUMBER
OTHER
PARTIES NOTIFIED

FIRST
MORTGAGEE

AGENT
INFORMATION

POLICY
TERM

IMPORTANT—PLEASE PRINT OR TYPE

LOAN NUMBER: ___________________________

PROPERTY
LOCATION

INSURED PROPERTY LOCATION

CANCELLATION REASON CODE

THIS POLICY MAY ONLY BE CANCELED UPON TERMINATION OF THE INSURED’S
OWNERSHIP IN THE PROPERTY COVERED AT THE LOCATION DESCRIBED ON THE
DECLARATION PAGE OF THE POLICY FOR REASON CODES (1) AND (2) BELOW.

13) VOIDANCE PRIOR TO EFFECTIVE DATE

2)

CONTENTS SOLD OR REMOVED

14) VOIDANCE DUE TO CREDIT CARD ERROR

3)

POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON EXPIRATION
DATE WITH OTHER INSURANCE COVERAGE

15) INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

4) DUPLICATE NFIP POLICIES

16) DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP

5) NON-PAYMENT

18) MORTGAGE PAID OFF ON MPPP POLICY

6) RISK NOT ELIGIBLE FOR COVERAGE

19) INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR
20) POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE
LOSS PROPERTY)

8) POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED BY
MORTGAGEE AS PROPERTY NOT IN SFHA

21) OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

REFUND

9) INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

SIGNATURE

C ANCELLATION REASON CODE: __________

1) BUILDING SOLD OR REMOVED

7) PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

C
E
R
T
I
F
I
C
A
T
I
O
N

22) CANCEL/REWRITE DUE TO MISRATING

10) CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP

23) FRAUD (FEMA APPROVAL REQUIRED)

12) MORTGAGE PAID OFF

24) CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

C
O
P
Y

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 OR AT REQUEST OF INSURED)

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENT MAY BE PUNISHABLE BY FINE OR IMPRISONMENT
UNDER 18 U.S. CODE, SECTION 1001. INSURANCE AGENT ALSO CERTIFIES THAT ITEMS ON THE REVERSE HAVE BEEN DISCUSSED WITH INSURED.
_________________________________________
SIGNATURE OF INSURED

(NOT REQUIRED FOR REASON 5, 6, OR 22)

FEMA Form 086-0-2, AUG 09

_____ / _____ / _______
MM

DD

YYYY

_________________________________________
SIGNATURE OF AGENT/BROKER

_____ / _____ / _______
MM

DD

YYYY

AGENT/BROKER TAX ID _________________________________________________________

Previously FEMA Form 81-17

F-052 (8/09)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT: SEND ORIGINAL TO NFIP, KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO THE INSURED, AND FOURTH COPY TO MORTGAGEE.

FLOOD INSURANCE
CANCELLATION/NULLIFICATION REQUEST FORM
FEMA FORM 086-0-2

NONDISCRIMINATION
No person or organization shall be excluded from participation in, denied the benefits of, or subjected to
discrimination under the Program authorized by the Act, on the grounds of race, color, creed, sex, age or
national origin.
PRIVACY ACT
The information requested is necessary to process your Flood Insurance Application for a flood insurance
policy. The authority to collect the information is Title 42, U.S. Code, Sections 4001 to 4028. Disclosures of
this information may be made: to federal, state, tribal, and local government agencies, fiscal agents, your
agent, mortgage servicing companies, insurance or other companies, lending institutions, and
contractorsworking for us, for the purpose of carrying out the National Flood Insurance Program; to
current Severe Repetitive Loss property owners and Preferred Risk Policy owners for the purpose of
property loss history evaluation; to the American Red Cross for verification of nonduplication of benefits
following a flooding event or disaster; to law enforcement agencies or professional organizations when
there may be a violation or potential violation of law; to a federal, state or local agency when we request
information relevant to an agency decision concerning issuance of a grant or other benefit, or in certain
circumstances when a federal agency requests such information for a similar purpose from us; to a
Congressional office in response to an inquiry made at the request of an individual; to the Office of
Management and Budget (OMB) in relation to private relief legislation under OMB Circular A-19; and to the
National Archives and Records Administration in records management inspections. Providing the
information is voluntary, but failure to do so may delay or prevent issuance of the flood insurance policy.

GENERAL
This information is provided pursuant to Public Law 96-511 (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
Public reporting burden for this data collection is estimated to average 7.5 minutes 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 this form. You are not required to
respond to this collection of information unless a valid OMB control number is displayed on this form. 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, Paperwork Reduction Project (1660-0006).
NOTE: Do not send your completed form to this address.