Form FEMA Form 086-0-3 FEMA Form 086-0-3 Flood Insurance General Change Endorsement

THIS LAYOUT OF THE REVISED GENERAL CHANGE ENDORSEMENT, PAGE 1 OF 2, 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 GENERAL CHANGE ENDORSEMENT, PAGE 1 (OF 2)

POLICY #:

FOR ALL POLICY TYPES. IMPORTANT—PLEASE PRINT OR TYPE; ENTER DATES AS MM/DD/YYYY.
REASON FOR ASSIGNMENT:
NEW PURCHASE
DATE OF PURCHASE:
/
/
OTHER (SPECIFY):

PROPERTY LOCATION

NOTE: ONE BUILDING PER POLICY — BLANKET COVERAGE NOT PERMITTED.
YES
NO
IS INSURED PROPERTY LOCATION SAME AS INSURED’S MAILING ADDRESS?
IF NO, ENTER PROPERTY ADDRESS. IF RURAL, ENTER LEGAL DESCRIPTION, OR GEOGRAPHIC
LOCATION OF PROPERTY (DO NOT USE P.O. BOX).
IDENTIFY ADDRESS TYPE:
STREET
LEGAL  DESCRIPTION*
GEOGRAPHIC LOCATION

/

/

WAITING PERIOD:
 STANDARD 30-DAY
REQUIRED FOR LOAN TRANSACTION — NO WAITING PERIOD
MAP REVISION (ZONE CHANGE FROM NON-SFHA TO SFHA) — 1 DAY
TRANSFER (NFIP ONLY) — NO WAITING PERIOD

PHONE NO.:
IS THE INSURED A SMALL BUSINESS?
IS THE INSURED A NON-PROFIT ENTITY?

YES
YES

NO
NO

NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:

LOAN NO.:

* LEGAL DESCRIPTION MAY BE USED ONLY WHILE A BUILDING OR SUBDIVISION IS IN THE
COURSE OF CONSTRUCTION OR PRIOR TO ESTABLISHING A STREET ADDRESS.
GRANDFATHERING INFORMATION
YES
NO
IF YES,
BUILT IN COMPLIANCE OR
GRANDFATHERED?
CONTINUOUS COVERAGE (PROVIDE PRIOR POLICY NUMBER IN BOX ABOVE)
RATING MAP INFORMATION
NAME OF COUNTY/PARISH:
COMMUNITY NO./PANEL NO. AND SUFFIX:
FIRM ZONE:

MAP DATE:
COMMUNITY PROGRAM TYPE IS:
REGULAR

–
/
/
EMERGENCY

CURRENT MAP INFORMATION
CURRENT COMMUNITY NO./PANEL NO. AND SUFFIX:
CURRENT FIRM ZONE:
MAP DATE:

/

–

CURRENT BFE:
/

NEWLY MAPPED INFORMATION
DATE THE BUILDING WAS NEWLY MAPPED INTO THE SFHA:
1. BUILDING PURPOSE
100% RESIDENTIAL
100% NON-RESIDENTIAL
MIXED-USE — SPECIFY PERCENTAGE OF
RESIDENTIAL USE:
%
2. BUILDING OCCUPANCY
SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL BUSINESS
OTHER NON-RESIDENTIAL
3. IS THE BUILDING A HOUSE OF WORSHIP?
YES
NO
4. IS THE BUILDING AN AGRICULTURAL
YES
NO
STRUCTURE?
5. BUILDING DESCRIPTION (CHECK ONE)
MAIN HOUSE
DETACHED GUEST HOUSE
DETACHED GARAGE
BARN
APARTMENT BUILDING
APARTMENT – UNIT
COOPERATIVE BUILDING
COOPERATIVE – UNIT
WAREHOUSE
TOOL/STORAGE SHED

/

/

6. CONDOMINIUM INFORMATION
IS BUILDING IN A CONDOMINIUM FORM
OF OWNERSHIP?
YES
NO
IS COVERAGE FOR THE ENTIRE BUILDING?
YES
NO
TOTAL NUMBER OF UNITS:
HIGH-RISE
LOW-RISE
IS COVERAGE FOR A CONDOMINIUM UNIT?
YES
NO
7. A DDITIONS AND EXTENSIONS
(IF APPLICABLE)
DOES THE BUILDING HAVE ANY ADDITIONS
OR EXTENSIONS?
YES
NO
(ADDITIONS AND EXTENSIONS MAY BE
SEPARATELY INSURED.)
COVERAGE IS FOR:
BUILDING INCLUDING ADDITION(S)
AND EXTENSION(S)
BUILDING EXCLUDING ADDITION(S) AND
EXTENSION(S) PROVIDE POLICY NUMBER
FOR ADDITION OR EXTENSION:

IF YES, NUMBER OF PERMANENT FLOOD
OPENINGS WITHIN 1 FOOT ABOVE THE
ADJACENT GRADE:
.

TOTAL NET AREA OF THE GARAGE:
SQUARE FEET.

TOTAL AREA OF ALL PERMANENT OPENINGS:
SQUARE INCHES.
IS THE GARAGE USED SOLELY FOR PARKING
OF VEHICLES, BUILDING ACCESS, AND/OR
STORAGE?
YES
NO
IF YES, DOES THE GARAGE CONTAIN
MACHINERY AND/OR EQUIPMENT?
YES
NO

NAME AND MAILING ADDRESS OF:

2ND MORTGAGEE

YES

NO

LOSS PAYEE

OTHER

IF OTHER, SPECIFY:

LOAN NO.:
IS INSURANCE REQUIRED UNDER MANDATORY PURCHASE?

YES

NO

COMPLETE THIS SECTION ONLY FOR PRE-FIRM BUILDINGS LOCATED IN AN SFHA.
1. HAS THE APPLICANT HAD A PRIOR NFIP POLICY FOR THIS PROPERTY?
YES
NO
2. WAS THE POLICY REQUIRED BY THE LENDER UNDER MANDATORY PURCHASE?
YES
NO
3. IF YES, HAS THE PRIOR NFIP POLICY EVER LAPSED WHILE COVERAGE WAS REQUIRED
YES
NO
UNDER MANDATORY PURCHASE BY THE LENDER?
4. IF YES, WAS THE LAPSE THE RESULT OF A COMMUNITY SUSPENSION?
YES
NO

IF YES, WHAT IS THE SUSPENSION DATE?

/

/

WHAT IS THE REINSTATEMENT DATE?
/
/
5. WILL THIS POLICY BE EFFECTIVE WITHIN 180 DAYS OF THE COMMUNITY REINSTATEMENT
YES
NO
AFTER SUSPENSION REFERRED TO IN (4) ABOVE?
ADDITION OR EXTENSION ONLY (INCLUDE
DESCRIPTION IN THE PROPERTY
LOCATION BOX ABOVE). PROVIDE POLICY
NUMBER FOR BUILDING EXCLUDING
ADDITION(S) OR EXTENSION(S):

POOLHOUSE, CLUBHOUSE, RECREATION
BUILDING
OTHER:

1. GARAGE
IS A GARAGE ATTACHED TO THE BUILDING?
YES
NO

ARE THERE ANY OPENINGS (EXCLUDING
DOORS) THAT ARE DESIGNED TO ALLOW THE
PASSAGE OF FLOODWATERS THROUGH THE
GARAGE?
YES
NO

2ND MORTGAGEE/OTHER

IS INSURANCE REQUIRED UNDER MANDATORY PURCHASE?

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE THE INSURED BUILDING:

COMMUNITY

/
/
POLICY PERIOD IS FROM
TO
12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.

INSURED
INFORMATION

FAX NO.:

EMAIL ADDRESS:

1ST MORTGAGEE

AGENT’S TAX ID:

AGENCY NO.:
PHONE NO.:

ALL BUILDINGS

LOSS PAYEE
OTHER (AS SPECIFIED IN THE “2ND
MORTGAGEE/OTHER” BOX BELOW)

NAME AND MAILING ADDRESS OF INSURED:

PRIOR NFIP COVERAGE

AGENT/PRODUCER
INFORMATION

NAME AND MAILING ADDRESS OF AGENT/PRODUCER:

NON-ELEVATED BUILDINGS

FOR RENEWAL, BILL:
INSURED
FIRST MORTGAGEE
SECOND MORTGAGEE

BILLING

MAILING ADDRESS
BILLING
AGENT/PRODUCER

POLICY PERIOD

MORTGAGEE
INCREASE COVERAGE
BUILDING INFORMATION
INSURED INFORMATION
OTHER (SPECIFY):

ASSIGNMENT

CHANGE

REASON FOR CHANGE (CHECK ALL THAT APPLY)

8. P RIMARY RESIDENCE, RENTAL
PROPERTY, TENANT’S COVERAGE
IS BUILDING INSURED’S PRIMARY
RESIDENCE?
YES
NO
IS BUILDING A RENTAL PROPERTY?
YES
NO
YES
NO
IS THE INSURED A TENANT?
IF YES, IS THE TENANT REQUESTING BUILDING
YES
NO
COVERAGE?
IF YES, SEE NOTICE IN SIGNATURE BLOCK
ON PAGE 2.
9. BUILDING INFORMATION
IS BUILDING IN THE COURSE OF
CONSTRUCTION?
YES
NO
IS BUILDING WALLED AND ROOFED?
YES
NO
IS BUILDING OVER WATER?
NO
PARTIALLY
ENTIRELY
2. BASEMENT/SUBGRADE CRAWLSPACE
DOES THE BASEMENT/SUBGRADE
CRAWLSPACE CONTAIN MACHINERY AND/OR
YES
NO
EQUIPMENT?
IF YES, SELECT THE VALUE BELOW:
UP TO $10,000
$10,001 TO $20,000
IF GREATER THAN $20,000 – INDICATE
THE AMOUNT:

IS BUILDING LOCATED ON FEDERAL LAND?
YES
NO
IS BUILDING A SEVERE REPETITIVE LOSS
YES
NO
PROPERTY?

10. IS BUILDING ELEVATED?

YES

NO

11. BASEMENT, ENCLOSURE, CRAWLSPACE
NONE
FINISHED BASEMENT/ENCLOSURE
CRAWLSPACE
UNFINISHED BASEMENT/ENCLOSURE
SUBGRADE CRAWLSPACE
IS THE BASEMENT/SUBGRADE CRAWLSPACE
FLOOR BELOW GRADE ON ALL SIDES?
YES
NO
12. NUMBER OF FLOORS IN BUILDING
(INCLUDING BASEMENT/ENCLOSED
AREA, IF ANY) OR BUILDING TYPE
1
2
3 OR MORE
SPLIT LEVEL
TOWNHOUSE/ROWHOUSE (RCBAP
LOW-RISE ONLY)
MANUFACTURED (MOBILE) HOME/TRAVEL
TRAILER ON FOUNDATION

DOES THE BASEMENT/SUBGRADE
CRAWLSPACE CONTAIN A WASHER, DRYER
YES
NO
OR FOOD FREEZER?
IF YES, SELECT THE VALUE BELOW:
UP TO $5,000
$5,001 TO $10,000
IF GREATER THAN $10,000 – INDICATE
THE AMOUNT:

PLEASE SUBMIT TOTAL AMOUNT DUE AND ALL REQUIRED CERTIFICATIONS WITH THE NFIP COPY OF THIS APPLICATION.
IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
IMPORTANT — COMPLETE PAGE 1 AND PAGE 2 BEFORE SENDING APPLICATION TO THE NFIP. — IMPORTANT

N
F
I
P
C
O
P
Y

THIS LAYOUT OF THE REVISED GENERAL CHANGE ENDORSEMENT, PAGE 2 OF 2, 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

FLOOD INSURANCE GENERAL CHANGE
ENDORSEMENT, PAGE 2 (OF 2)

National Flood Insurance Program
FOR ALL POLICY TYPES. IMPORTANT—PLEASE PRINT OR TYPE; ENTER DATES AS MM/DD/YYYY.

POLICY #:

ALL DATA PROVIDED BY THE INSURED OR OBTAINED FROM THE ELEVATION CERTIFICATE SHOULD BE REVIEWED
AND TRANSCRIBED BELOW. THIS PART OF THE APPLICATION MUST BE COMPLETED FOR ALL BUILDINGS.

ELEVATED BUILDINGS (INCLUDING
MANUFACTURED [MOBILE] HOMES/
TRAVEL TRAILERS)

DOES THE AREA BELOW THE ELEVATED
FLOOR CONTAIN A WASHER, DRYER OR
FOOD FREEZER?
YES
NO
IF YES, SELECT THE VALUE BELOW:
UP TO $5,000
$5,001 TO $10,000
IF GREATER THAN $10,000 – INDICATE
THE AMOUNT:

ELEVATION
DATA

2. ELEVATING FOUNDATION TYPE
PIERS, POSTS, OR PILES
REINFORCED MASONRY PIERS OR
CONCRETE PIERS OR COLUMNS
REINFORCED CONCRETE SHEAR WALLS
WOOD SHEAR WALLS
SOLID FOUNDATION WALLS

4. AREA BELOW THE ELEVATED FLOOR
IS THE AREA BELOW THE ELEVATED FLOOR
ENCLOSED?
YES
NO
IF YES, CHECK ONE OF THE FOLLOWING:
FULLY
PARTIALLY

3. MACHINERY AND/OR EQUIPMENT

IS THERE A GARAGE? (CHECK ONE)
NO GARAGE
BENEATH THE LIVING SPACE
NEXT TO THE LIVING SPACE

DOES THE AREA BELOW THE ELEVATED
FLOOR CONTAIN MACHINERY AND/OR
EQUIPMENT?
YES
NO
IF YES, SELECT THE VALUE BELOW:
UP TO $10,000
$10,001 TO $20,000
IF GREATER THAN $20,000 – INDICATE
THE AMOUNT:

PARKING OF VEHICLES, BUILDING ACCESS
YES
NO
AND/OR STORAGE?
IF YES, DESCRIBE:

INDICATE MATERIAL USED FOR ENCLOSURE:
INSECT SCREENING
LIGHT WOOD LATTICE
SOLID WOOD FRAME WALLS (IF
BREAKAWAY, SUBMIT CERTIFICATION
DOCUMENTATION)
SOLID WOOD FRAME WALLS (NONBREAKAWAY)
MASONRY WALLS (IF BREAKAWAY,
SUBMIT CERTIFICATION
DOCUMENTATION)
MASONRY WALLS (NON-BREAKAWAY)
OTHER (DESCRIBE):

DOES THE ENCLOSED AREA HAVE MORE
THAN 20 LINEAR FEET OF FINISHED
INTERIOR WALL, PANELING, ETC.?
YES
NO
5. FLOOD OPENINGS
IS THE ENCLOSED AREA/CRAWLSPACE
CONSTRUCTED WITH OPENINGS (EXCLUDING
DOORS) TO ALLOW THE PASSAGE OF
FLOODWATERS THROUGH THE
ENCLOSED AREA?
YES
NO
IF YES, INDICATE NUMBER OF PERMANENT
FLOOD OPENINGS WITHIN 1 FOOT
ABOVE ADJACENT GRADE:
.

TOTAL AREA OF ALL PERMANENT
FLOOD OPENINGS:

IF ENCLOSED WITH A MATERIAL OTHER THAN
INSECT SCREENING OR LIGHT WOOD LATTICE,
PROVIDE THE SIZE OF ENCLOSED AREA:

DOES THE AREA BELOW THE ELEVATED
FLOOR CONTAIN ELEVATORS?
YES
NO
IF YES, HOW MANY?

SQUARE INCHES.
ARE FLOOD OPENINGS ENGINEERED?
YES
NO
IF YES, SUBMIT CERTIFICATION.

SQUARE FEET

IS THE ENCLOSED AREA/CRAWLSPACE USED
FOR ANY PURPOSE OTHER THAN SOLELY FOR

NOTE: WHEELS MUST BE REMOVED FOR TRAVEL TRAILER TO BE INSURABLE.

2. ANCHORING

1. MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER DATA

THE MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER ANCHORING SYSTEM UTILIZES:
(CHECK ALL THAT APPLY.)
OVER-THE-TOP TIES
GROUND ANCHORS
FRAME TIES
SLAB ANCHORS
FRAME CONNECTORS
OTHER (DESCRIBE):

YEAR OF MANUFACTURE:
MAKE:
MODEL NUMBER:

3. INSTALLATION

SERIAL NUMBER:
DIMENSIONS:
×
FEET
ARE THERE ANY PERMANENT ADDITIONS AND/OR EXTENSIONS?
IF YES, THE DIMENSIONS ARE:

×

YES

THE MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER WAS INSTALLED IN ACCORDANCE
WITH: (CHECK ALL THAT APPLY.)
MANUFACTURER’S SPECIFICATIONS
LOCAL FLOODPLAIN MANAGEMENT STANDARDS
STATE AND/OR LOCAL BUILDING STANDARDS

NO

FEET

CHECK ONE OF THE FOLLOWING AND ENTER DATE FOR ORIGINAL CONSTRUCTION:
BUILDING PERMIT
CONSTRUCTION
/
/
CHECK IF BUILDING HAS BEEN SUBSTANTIALLY IMPROVED AND ENTER DATE:
SUBSTANTIAL IMPROVEMENT
/
/

CONTENTS LOCATED IN:*
BASEMENT/ENCLOSURE
BASEMENT/ENCLOSURE AND ABOVE
LOWEST FLOOR ONLY ABOVE GROUND LEVEL
LOWEST FLOOR ABOVE GROUND LEVEL AND HIGHER
ABOVE GROUND LEVEL MORE THAN 1 FULL FLOOR

CONTENTS

CONSTRUCTION
INFORMATION

MANUFACTURED (MOBILE) HOMES/
TRAVEL TRAILERS

ELEVATED BUILDINGS

1. IF THE BUILDING IS ELEVATED, IS THE
AREA BELOW
FREE OF OBSTRUCTION
WITH OBSTRUCTION

IF THE ANSWER TO ANY OF THE QUESTIONS
REGARDING THE AREA BELOW THE
ELEVATED FLOOR IS YES, OR THERE IS A
GARAGE, ANSWER ALL THE FOLLOWING.

CHECK ONE OF THE FOLLOWING FOR MANUFACTURED (MOBILE) HOMES/TRAVEL TRAILERS:
LOCATED OUTSIDE A MOBILE HOME PARK OR SUBDIVISION: DATE OF PERMANENT PLACEMENT
LOCATED INSIDE A MOBILE HOME PARK OR SUBDIVISION: CONSTRUCTION DATE OF MOBILE
HOME PARK OR SUBDIVISION FACILITIES
ELEVATION CERTIFICATION DATE:

(IF POST-FIRM CONSTRUCTION IN
ZONES A, 1–A30, AE, AO, AH, V,
V1–V30, VE, OR IF PRE-FIRM
CONSTRUCTION IS ELEVATION RATED,
ATTACH ELEVATION CERTIFICATE.)

IN ZONES V AND V1–V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?

/

/

LOWEST ADJACENT GRADE (LAG):
(−) BASE FLOOD ELEVATION:

LOWEST FLOOR ELEVATION:

NO

IF NO, DESCRIBE:
*IF SINGLE FAMILY, CONTENTS ARE RATED THROUGHOUT THE BUILDING.

IS BUILDING POST-FIRM CONSTRUCTION?
YES
NO

BUILDING DIAGRAM NO.:

YES

IS PERSONAL PROPERTY HOUSEHOLD CONTENTS?

(=) DIFFERENCE TO NEAREST FOOT:
YES

(+ OR −)

NO

YES
NO
IS BUILDING FLOODPROOFED?
(SEE THE NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION REQUIREMENTS.)

ESTIMATED BUILDING REPLACEMENT COST (INCLUDING FOUNDATION): $

DEDUCTIBLE: BUILDING $

CONTENTS $

TO INCREASE/DECREASE COVERAGE, COMPLETE SECTIONS A & B. FOR RATE CHANGE, COMPLETE SECTION A ONLY.
INDICATE THE RATE TABLE USED:
RISK RATING METHOD:
7 – PRP
R – NEWLY MAPPED

COVERAGE AND RATING

SECTION A – CURRENT LIMITS
INSURANCE COVERAGE
BUILDING BASIC LIMIT

SECTION B – NEW LIMITS

AMOUNT

RATE

PREMIUM

AMOUNT

RATE

PREMIUM

BUILDING

CONTENTS

PREMIUM

BUILDING

CONTENTS

PREMIUM

BUILDING ADDITIONAL LIMIT
CONTENTS BASIC LIMIT
CONTENTS ADDITIONAL LIMIT
FOR PRP AND NEWLY MAPPED ONLY, ENTER LIMITS
FROM THE NFIP FLOOD INSURANCE MANUAL

IF CHANGING AMOUNT OF INSURANCE, ENTER NEW TOTAL AMOUNT BELOW
BUILDING COVERAGE
BASIC

ADDITIONAL

PAYMENT METHOD:

CONTENTS COVERAGE
TOTAL

IF RETURN PREMIUM, MAIL REFUND TO:

INSURED

BASIC

ADDITIONAL

AGENT/PRODUCER

CHECK
CREDIT CARD
OTHER:

TOTAL

SIGNATURE

DEDUCTIBLE DISCOUNT/SURCHARGE
SUBTOTAL
ICC PREMIUM
SUBTOTAL

PAYOR

NOTICE: BUILDING COVERAGE BENEFITS — EXCEPT FOR A RESIDENTIAL CONDOMINIUM BUILDING — ARE NOT AVAILABLE IF OTHER NFIP
BUILDING COVERAGE HAS BEEN PURCHASED BY THE APPLICANT OR ANY OTHER PARTY FOR THE SAME BUILDING.
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 REVERSE SIDE OF COPIES.

CRS PREMIUM DISCOUNT

%

SUBTOTAL
RESERVE FUND

%

SUBTOTAL

/

/

PREMIUM PREVIOUSLY PAID (Excludes
Probation Surcharge/Federal Policy Fee)

/

/

HFIAA SURCHARGE

/

/

SIGNATURE OF INSURANCE AGENT/PRODUCER

DATE (MM/DD/YYYY)

SIGNATURE OF INSURED (IF APPLICABLE)

DATE (MM/DD/YYYY)

SIGNATURE OF ASSIGNEE (FOR ASSIGNMENT ONLY)

SUBTOTAL

DATE (MM/DD/YYYY)

DIFFERENCE

(+/–)

PRO-RATA FACTOR

TOTAL AMOUNT DUE

PLEASE SUBMIT TOTAL AMOUNT DUE AND ALL REQUIRED CERTIFICATIONS WITH THE NFIP COPY OF THIS APPLICATION.
IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
IMPORTANT — COMPLETE PAGE 1 AND PAGE 2 BEFORE SENDING APPLICATION TO THE NFIP. — IMPORTANT

(+/–)

A+B
PREMIUM

N
F
I
P
C
O
P
Y

National Flood Insurance Program

FLOOD INSURANCE GENERAL CHANGE ENDORSEMENT
FEMA FORM 086-0-3
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
current Severe Repetitive Loss property owners and Preferred Risk Policy 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 9 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,
1800 South Bell Street, Arlington VA 20598-3005, Paperwork Reduction Project (1660-0033).
NOTE: Do not send your completed form to this address.