Form 086-0-26A Elevation Form

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

O.M.B. NO. 1660-0015

ElEVATION FORM

Expires December 3 I, 2010

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1.25 hours per response. The burden estimate 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, U,S, Department of Homeland Security, Federal Emergency
Management Agency, 500 C Street, SW, Washington DC 20472, Paperwork Reduction Project (1660-0015), Submission of the form is required to obtain or retain
benefits under the National Flood Insurance Program. Please do not send your completed survey to the above address.
This form must be completed for requests and must be completed and signed by a registered professional engineer or licensed land surveyor. A DHS - FEMA National
Flood Insurance Program (NF!Pl Elevation Certificate may be submitted In lieu of this form for single structure requests.
For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area (SFHA), submit the lowest adjacent grade (the lowest
ground touching the structure), including an attached deck or garage. For requests to remove an entire parcel of land from the SFHA, provide the lowest lot elevation;
or, if the request involves an area described by metes and bounds, provide the lowest elevation within the metes and bounds description, All measurements are to be
rounded to nearest tenth of a foot. In order to process your request, all information on this form must be completed in its entirety. Incomplete submissions will
result in
Property Name or Address:

1.

NFIP Community Number:

2.

Are the elevations listed below based on

3.

For the existing or proposed structures listed below, what are the
basement/enclosure
slab on grade
crawl space

4.

existing or

proposed conditions? (Check one)

instructions)

Has DHS - FEMA identified this area as subject to land subsidence or uplift?

/

If yes, what is the date of the current

5.

of construction? (check all that apply)
other (explain)
Yes

ONo

(month/year)

If any of the elevations listed below were
NAVD 88
Other (explain)
NGVD 29
What is the elevation datum?
NGVD 29 or NAVD 88), what
computed using a datum different than the datum used forthe effective Flood Insurance Rate Map (FIRM)
was the conversion factor?
local Elevation

6.

+/- ft. ::: FIRM Datum
of the

of the most

Please provide the Latitude and
Indicate Datum:

NAD83

WGS84

Please provide the Latitude and Longitude of the most upstream edge of the
Indicate Datum:

0

WGS84

0

NAD83

structure (in decimal degrees to the nearest fifth decimal

NAD27

0

Lat.

NAD27

Lat,.

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Address

Number

,

Block
Number

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lowest lot
Elevation'

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Long.

property (in decimal degrees to the nearest fifth decimal place):

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lowest
Adjacent
Grade To
Structure

long.

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Base Flood

BFE Source

Elevation

!

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This certification is to be Signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify elevation
information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable
by fine or imprisonment under Title 18 of the United States Code, Section 1001.
Certifier's Name:

licen se No.:

Company Name:

Telephone No.:

Email:

Fax No.

Signature:

Date:

'For requests involving a portion of property, include the lowest ground elevation within the metes and bounds description.
Please nole: If the Lowest Adjacent Grade to Structure is the only elevation provided. a determination will be issued
for the struclure only,

DHS - FEMA Form 086-0-26A, DEC 10

Elevation Form

Expiration Date:

L

Seal (optional)

MT·1 Form 2 Page 1 of 2

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Continued from Page 1.

Address

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Number

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lowest lot
Elevation"

Block Number

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lowest Ad J3 cent
Grade To
Structure

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BFE Source

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Base Flood
Elevation

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This certification is to be Signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify elevation
information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable
by fine or imprisonment under Title 18 of the United States Code, Section 100l.
Certifiers Name:

I License No.:

1 Expiration Date:

Company Name:

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Email:

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Signature:

I Date

'For requests Involving a
Please note! If Ihe
fOr the structure only.

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!

of property, include !he lowest ground elevalion within the metes and bounds descriptton
Grade 10 Struclure IS the only elevation provided. a determination will be issued

DHS - FEMA Form 086-0-26A, DEC 10

Elevation Form

MT-1 Form 2 Page 2 of 2