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DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.No.1660-0015 ELEVATION FORM Expires February 28,2014 PAPERWORK BURDEN DISCLOSURE NOTICE Faccuracy burden for this data collection is estimated to average 1.25 hours per response. The burden estimate includes the time for reviewing instructions, g data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain re not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security,Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form must be completed for requests and must be completed and signed by a registered professional engineer or licensed land surveyor. A DHS-FEMA National Flood Insurance Program(NFIP)Elevation Certificate may be submitted in lieu of this form for single structure requests. For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area(SFHA),submit the lowest adjacent grade(the lowest ground touching the structure),including an attached deck orgorage.For requests to remove an entire parcel of land from the SFHA,provide the lowest lot elevation; or,if the request involves an area described by metes and bounds,provide the lowest elevation within the metes and bounds description.All measurements are to be rounded to nearest tenth of a foot. In order to process your request,all information on this form must be completed in its entirety. Incomplete submissions will result in processing delays. 1. NAP Community Number: Property Name or Address: 2. Are the elevations listed below based on ❑existing or ❑proposed conditions? (Check one) 3. For the existing or proposed structures listed below,what are the types of construction? (check all that apply) ❑crawl space❑slab on grade ❑basement/enclosure ❑other(explain) 4. Has DHS-FEMA identified this area as subject to land subsidence or uplift?(see instructions) ❑Yes ❑No If yes,what is the date of the current re-leveling? / (month/year) S. What is the elevation datum?❑NGVD 29 ❑NAVD 88 ❑Other(explain) If any of the elevations listed below were computed using a datum different than the datum used for the effective Flood Insurance Rate Map (FIRM)(e.g.,NGVD 29 or NAVD 88),what was the conversion factor? Local Elevation+/-ft.=FIRM Datum 6. Please provide the Latitude and Longitude of the most upstream edge of the structure(in decimal degrees to the nearest fifth decimal place): Indicate Datum: ❑WGS84 ❑NAD83 ❑NAD27 Lat. Long. Please provide the Latitude and Longitude of the most upstream edge of the property(in decimal degrees to the nearest fifth decimal place): Indicate Datum: ❑WG584 ❑NAD83 ❑NAD27 Lat. Long. Lowest Block Lowest Lot Adjacent Base Flood Address Lot Number Number Elevation* Grade To Elevation BFE Source Structure This certification is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized by law to certify elevation information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement maybe punishable by fine or imprisonment under Title 18 of the United States Code,Section 1001. Certifier's Name: License No.. Expiration Date: Company Name: Telephone No.: Email: Fax No. Signature: Date: *For requests involving a portion of property,include the lowest ground elevation within the metes and bounds description. Seal(optional) Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a determination will be issued for the structure only. DHS-FEMA Form 086-0-26A, FEB 11 Elevation Form MT-1 Form 2 Page 1 of 2