FEMA Form 086-0-2T Flood Insurance Cancellation/Nullification Request

THIS LAYOUT OF THE REVISED FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM IS PROVIDED FOR YOUR REFERENCE.
THE FINAL FORM WILL BE RELEASED UPON O.M.B. APPROVAL.
U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

National Flood Insurance Program
Flood Insurance Cancellation/Nullification Request Form

POLICY #:

Policy Period Is From

Name and Mailing Address of Insured for Mailing Refund:

To

12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.
INSURED MAILING
INFORMATION

POLICY
PERIOD

IMPORTANT – Please print or type; enter dates as MM/DD/YYYY.

Cancellation Effective Date:

Phone No.:
Insured Property Location if Different from Insured’s Mailing Address:
INSURED PROPERTY
LOCATION

AGENT/PRODUCER INFORMATION

Agent/Producer information for the policy being canceled::

Agency No.:
Agent’s No.:
Phone No.:
FAX No.:
Email Address:

FIRST MORTGAGEE
INFORMATION

SECOND MORTGAGEE / OTHER
INFORMATION

Name and Mailing Address of First Mortgagee:

REFUND

CANCELLATION REASON
CODE

Loan No.:

Information below is that of:

Second Mortgagee

Loss Payee

Other (specify):

Please see all valid cancellation reason codes and requirements for their use in the
“How to Cancel” section of the NFIP Flood Insurance Manual on the FEMA website.
https://www.fema.gov/flood-insurance-manual

N
F
I
P
C
O
P
Y

CANCELLATION REASON CODE:

Make Refund Payable To (check one):

Insured

Payor

Agent (Reason Code 5 Only)

Mail Refund To (check one):

Insured

Payor

Agent (Reason Code 5 or at Request of Insured)

SIGNATURE

The above statements are correct to the best of my knowledge. I understand that any false statements may be punishable by fine and/or
imprisonment under applicable federal law. See second page of form.
SIGNATURE OF INSURED
(NOT REQUIRED FOR REASON CODES 5, 6, 22, OR 25)

DATE

SIGNATURE OF OTHER INSURED

DATE

SIGNATURE OF AGENT/PRODUCER

DATE

REPLACES ALL PREVIOUS EDITIONS.
PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SEND ORIGINAL TO NFIP, KEEP A COPY FOR YOUR RECORDS, AND PROVIDE COPIES TO THE INSURED AND MORTGAGEE(S).

F-052 (DEC 2019)

National Flood Insurance Program

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM
FEMA FORM 086-0-2T
NONDISCRIMINATION
No person or organization shall be excluded from participation in, denied the benefits of, or subjected to
discrimination under the Program authorized by the Act, on the grounds of race, color, creed, sex, age or
national origin.
PRIVACY ACT

The information requested is necessary to process your Flood Insurance Application for a flood insurance
policy. The authority to collect the information is Title 42, U.S. Code, Sections 4001 to 4028. Disclosures
of this information may be made: to federal, state, tribal, and local government agencies, fiscal agents, your
agent, mortgage servicing companies, insurance or other companies, lending institutions, and contractors
working for us, for the purpose of carrying out the National Flood Insurance Program; to certain property
owners for the purpose of property loss history evaluation; to the American Red Cross for verification of
nonduplication of benefits following a flooding event or disaster; to law enforcement agencies or professional
organizations when there may be a violation or potential violation of law; to a federal, state or local agency
when we request information relevant to an agency decision concerning issuance of a grant or other benefit,
or in certain circumstances when a federal agency requests such information for a similar purpose from us;
to a Congressional office in response to an inquiry made at the request of an individual; to the Office of
Management and Budget (OMB) in relation to private relief legislation under OMB Circular A-19; and to the
National Archives and Records Administration in records management inspections. Providing the information is
voluntary, but failure to do so may delay or prevent issuance of the flood insurance policy.
GENERAL

This information is provided pursuant to Public Law 96-511 (Paperwork Reduction Act of 1980, as amended),
dated December 11, 1980, to allow the public to participate more fully and meaningfully in the Federal
paperwork review process.
AUTHORITY

Public Law 96-511, amended, 44 U.S.C. 3507; and 5 CFR 1320.
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 7.5 minutes 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 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, 500 C Street SW, Washington, DC 20742, Paperwork
Reduction Project (1660-0006). NOTE: Do not send your completed form to this address.