Form FEMA Form 086-0-31 FEMA Form 086-0-31 Statement of Voluntary Participation for Acquisition of

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

O.M.B. No. 1660-0103
Expires August 31, 2011

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 this form 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 data needed, and completing and submitting the form. This
collection of information is voluntary. You are not required to respond to this collection of information unless a valid OMB control number
is displayed in the upper right corner of 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, 1800 South Bell Street, Arlington VA 20598-3005, Paperwork Reduction Project (1660-0103). NOTE: DO NOT SEND YOUR
COMPLETED FORM TO THIS ADDRESS.

FEMA 086-0-31

Previous FEMA Form 81-112, OCT 08

Privacy Act Statement

Authority: Sections 203 and 404 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended,
42 U.S.C. § 5133 and 42 U.S.C. § 5170c; § 1366 of the National Flood Insurance Act, (NFIA) as amended, 42 § U.S.C.
4104c; § 1323 of the NFIA, 42 U.S.C. § 4030; and § 1361A of the NFIA, 42 U.S.C. § 4102a.
Purpose: The information is being collected for the purpose of formalizing the purchase offer valuation of a property
subject to mitigation and to ensure that recipients of Hazard Mitigation Assistance funds for the acquisition and demolition
of these properties understand that their participation is strictly voluntary.
Routine Uses: 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.
Disclosure: The disclosure of information on this form is voluntary; however, failure to provide the information requested
may delay or prevent FEMA from being able to provide Hazard Mitigation Assistance for the acquisition and demolition of
the structure for the purposes of mitigation. The signed voluntary participation statement will be forwarded to the State/
applicant and the paper form will be contained in the grant application.

FEMA 086-0-31

Previous FEMA Form 81-112, OCT 08