Form FEMA Form 086-0-30 FEMA Form 086-0-30 Application for Participation in the National Flood Insu

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0004
Expires March 31, 2011

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. This collection of information is required to obtain or retain benefits.
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
estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management
Agency, 1800 South Bell Street, Arlington, VA 20598-3005, and Paperwork Reduction Project (1660-0004). NOTE: Do not send your completed form to this address.
DATE

1. APPLICANT COMMUNITY NAME (City, town, etc.)

COUNTY, STATE

2. COMMUNITY OFFICIAL - CHIEF EXECUTIVE OFFICER (CEO)

TELEPHONE NO. (Include area code)

E-MAIL ADDRESS

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

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

E-MAIL ADDRESS

TELEPHONE NO. (Include area code)

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)

60.3(d)

5. CHECK APPROPRIATE BOX:
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
PRIVACY ACT STATEMENT
AUTHORITY: The Federal Records Act, 44 U.S.C. 3101; National Flood Insurance Act of 1968, as amended; and Flood Disaster Protection Act of 1973, 42 U.S.C. 4001, et seq.
PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administration of communities' participation in the Federal Emergency Management
Agency's (FEMA) National Flood Insurance Program.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a (b) of the Privacy Act of 1974, as amended. This includes using this information as necessary
and authorized by the routine uses published in Department of Homeland Security/FEMA - 003 National Flood Insurance Program Files System of Records (December 19, 2008, 73 FR 77747) and upon
written request, by agreement, or as required by law.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent the community from participation in FEMA's National Flood
Insurance Program.

FEMA Form 086-0-30, MM/YY

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