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
APPLICATION FOR PARTICIPATION IN THE NATIONAL FLOOD INSURANCE
PROGRAM

O.M.B. NO. 1660-0004
Expires June 30, 2014

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, 500 C Street SW, Washington, DC 20472, and Paperwork Reduction Project (1660-0004). NOTE: Do not send your
completed form to this address.

APPLICANT COMMUNITY NAME (City, town, etc.)

DATE

COUNTY, STATE

COMMUNITY OFFICIAL - CHIEF EXECUTIVE OFFICER (CEO)

E-MAIL ADDRESS

TELEPHONE # (Include area
code)

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

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

E-MAIL ADDRESS

TELEPHONE # (Include area
code)

ADDRESS (Street or box #., city, state, zip code)

LOCATION OF COMMUNITY REPOSITORY FOR PUBLIC INSPECTION OF NFIP MAPS

ADDRESS

ESTIMATES FOR THOSE AREAS PRONE TO FLOOD AND/OR MUDSLIDE AS OF THE DATE OF THIS APPLICATION
AREA IN ACRES

NUMBER OF 1-4
FAMILYSTRUCTURES

POPULATION

NUMBER OF ALL
OTHER STRUCTURES

ESTIMATES OF TOTALS IN ENTIRE COMMUNITY

NUMBER OF 1-4
FAMILYSTRUCTURES

POPULATION

NUMBER OF ALL
OTHER STRUCTURES

FOR FEMA REGIONAL USE ONLY

FEMA REGIONAL OFFICE

NAME OF CONTACT

TELEPHONE NUMBER

LEVEL OF 44 CFR 60.3 REGULATION ADOPTED (Check one)
60.3

60.3(b)

60.3(c)

60.3(d)

60.3(e)

CHECK APPROPRIATE BOX:
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

FEMA FORM 086-0-30