Download:
pdf |
pdfDEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
RESIDENTIAL BASEMENT FLOODPROOFING CERTIFICATE
OMB Control Number: 1660-0033
Expiration: 11/30/2016
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 3.25 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 this
Residential Basement Floodproofing Certificate. 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 Residential Basement Floodproofing Certificate. 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 (1660-0033).
NOTE: Do not send your completed form to this address.
Privacy Act Statement
AUTHORITY
National Flood Insurance Act of 1968, as amended (42 U.S.C. § 4001 et seq.).
PRINCIPAL PURPOSE(S)
This information is being collected for two primary purposes. First, for community use in documenting compliance with floodplain
management ordinances, where records are maintained by the community. Second, for flood insurance purposes of estimating the risk
premium rates necessary to provide flood insurance for new or substantially improved structures in designated Special Flood Hazard Areas.
Records are located at the facility that underwrites and administers the policy (Write Your Own (WYO) companies or the Federal Emergency
Management Agency's (FEMA) National Flood Insurance Program (NFIP) Direct).
ROUTINE USE(S)
When this form is maintained by FEMA and is used in conjunction with the application and maintenance of a flood insurance policy, the
information requested on this form may be shared externally as a “routine use” to authorized WYO companies receiving transferred policies,
to assist the Department of Homeland Security (DHS)/FEMA in estimating the risk premium rates necessary to provide flood insurance for
new or substantially improved structures in designated Special Flood Hazard Areas. A complete list of the routine uses can be found in the
system of records notice associated with this form, “DHS/FEMA-003 - National Flood Insurance Program Files 79 Fed. Reg. 28,747 (May 19,
2014); and upon written request, written consent, by agreement, or as required by law. The Department's full list of system of records notices
can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.
DISCLOSURE
The disclosure of information on this form is voluntary; however, failure to provide the information requested may result in the inability to
obtain flood insurance through the National Flood Insurance Program, or the building being subject to higher premium rates for flood
insurance. Information will only be released as permitted by law.
FEMA FORM 086-0-24 (09/16)
Page 1 of 4
RESIDENTIAL BASEMENT FLOODPROOFING CERTIFICATE
FOR INSURANCE COMPANY USE
BUILDING OWNER'S NAME
POLICY NUMBER
BUILDING STREET ADDRESS (Including Apt., Unit Number)
COMPANY NAIC NUMBER
OTHER DESCRIPTION (Lot and Block Numbers, etc.)
CITY
STATE
ZIPCODE
SECTION I - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
Provide the following from the FIRM and flood profile (from Flood Insurance Study)
COMMUNITY
NUMBER
PANEL
NUMBER
SUFFIX
DATE OF
FIRM
ZONE
Indicate elevation datum used for Base Flood Elevation shown above:
BASE FLOOD ELEVATION
(In AO Zones, Use depth)
NGVD 1929
NAVD 1988
NAME OF FLOODING SOURCE(S)
AFFECTING BUILDING
Other/Source:
SECTION II - FLOODPROOFED ELEVATION CERTIFICATION (By a Registered Professional Land Surveyor, Engineer, or Architect)
All elevations must be based on finished construction.
Floodproofing Elevation Information for Zones A1-30, AE, AH, AO:
Building is floodproofed to an elevation of
feet.
.
(Elevation datum used must be the same as that on the FIRM.)
Elevation of the top of the basement floor is
feet.
.
(In Puerto Rico only:
.
meters.)
(In Puerto Rico only:
.
meters.)
Lowest adjacent (finished) grade next to the building (LAG):
.
feet.
(In Puerto Rico only:
.
meters.)
Highest adjacent (finished) grade next to the building (HAG):
.
feet.
(In Puerto Rico only:
.
meters.)
Indicate elevation datum used for Section II:
NGVD 1929
NAVD 1988
Other/Source:
(NOTE: For insurance rating purposes, the building's floodproofed elevation must be at least 1 foot above the Base Flood Elevation to receive
rating credit. If the building is floodproofed only to the Base Flood Elevation, then the building's insurance rating will result in a higher
premium.)
Section II certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information.
I certify that the information in Section II on this Certificate represents a true and accurate interpretation and determination by the undersigned
using the available information and data. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S.
Code, Section 1001.
CERTIFIER'S NAME
LICENSE NUMBER (or affix Seal)
TITLE
COMPANY NAME
ADDRESS
CITY
STATE
SIGNATURE
PHONE NO.
DATE
ZIP CODE
Place Seal Here
FEMA FORM 086-0-24 (09/16)
Page 2 of 4
RESIDENTIAL BASEMENT FLOODPROOFING CERTIFICATE cont.
BUILDING STREET ADDRESS (Including Apt., Unit Number)
CITY
STATE
ZIPCODE
SECTION III - FLOODPROOFING CERTIFICATION (By a Registered Professional Engineer or Architect)
Residential Floodproofed Basement Construction Certification:
I certify the structure, based upon development and/or review of the design, specifications, as-built drawings for construction and physical
inspection, has been designed and constructed in accordance with the accepted standards of practice (ASCE 24-05, ASCE 24-14, or their
equivalent) and any alterations also meet those standards and the following provisions.
* Basement area, together with attendant utilities and sanitary facilities, is watertight to the floodproofing design
elevation with walls that are impermeable to the passage of water without human intervention; and
* Basement walls and floor are capable of resisting hydrostatic and hydrodynamic loads and the effects of buoyancy
resulting from flooding to the floodproofing design elevation; and have been designed so that minimal damage will
occur from floods that exceed the floodproofing design elevation; and
* Building design, including the floodproofing design elevation, complies with community requirements; and
* Soil or fill adjacent to the structure is compacted and protected against erosion and local scour (in accordance with ASCE 24).
I certify that the information in Section III on this certificate represents a true and accurate determination by the undersigned using the available
information and data. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
CERTIFIER'S NAME
LICENSE NUMBER (or affix Seal)
TITLE
COMPANY NAME
ADDRESS
CITY
STATE
SIGNATURE
PHONE NO.
DATE
ZIP CODE
Place Seal Here
Copies of this certificate must be given to: 1) the community official: 2) the insurance agent: and 3) the building owner.
FEMA FORM 086-0-24 (09/16)
Page 3 of 4
RESIDENTIAL BASEMENT FLOODPROOFING CERTIFICATE cont.
Instructions for Completing the Residential Basement Floodproofing Certificate
To receive credit for floodproofing, a completed Residential Basement Floodproofing Certificate is required for residential buildings with
basements in Regular Program communities, located in zones A1 -A30, AE, AR, AR Dual, AO, AH, and A with BFE.
The communities must have been specifically approved and authorized by FEMA to receive residential basement floodproofing rating credit.
Approved communities are listed in the Special Certifications section of the NFIP Flood Insurance Manual, available on the FEMA website at
https://www.fema.gov/flood-insurance-manual.
When applying for flood insurance, the following information must be provided with the completed Residential Basement Floodproofing
Certificate:
• The Flood Insurance Application
• At least two photographs of the building.
FEMA FORM 086-0-24 (09/16)
Page 4 of 4
| File Type | application/pdf |
| File Title | FEMA Form |
| File Modified | 2017-03-16 |
| File Created | 2017-03-14 |