Fema Form 81-64 - Application For Participation In The National Flood Insurance Program - 2006-2008
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1DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
O.M.B. NO. 1660-0004
APPLICATION FOR PARTICIPATION IN THE NATIONAL FLOOD
Expires February 29, 2008
INSURANCE PROGRAM
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 needed data, and completing, reviewing, and submitting
the form. You are not required to submit to this collection of information unless a valid OMB control number appears 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 20472, Paperwork Reduction Project (1660-0004). Please do not send your completed form to the address above.
1. APPLICANT COMMUNITY NAME (City, town, etc.)
DATE
COUNTY, STATE
2. COMMUNITY OFFICIAL - CHIEF EXECUTIVE OFFICER (CEO)
E-MAIL ADDRESS
TELEPHONE NO. (Include area
code)
ADDRESS (Street or box no., city , state, zip code)
3. PROGRAM COORDINATOR
E-MAIL ADDRESS
TELEPHONE NO. (Include area
(Official, if different from above, with overall
code)
responsibility for implementing program)
ADDRESS (Street or box no., city , state, zip code)
4. LOCATION OF COMMUNITY REPOSITORY FOR PUBLIC INSPECTION OF NFIP MAPS
ADDRESS
5. ESTIMATES FOR THOSE AREAS PRONE TO FLOOD AND/OR MUDSLIDE AS OF THE DATE OF THIS APPLICATION
NO. OF 1-4
NO. OF ALL
AREA IN ACRES
POPULATION
FAMILY
OTHER
STRUCTURES
STRUCTURES
6. ESTIMATES OF TOTALS IN ENTIRE COMMUNITY
NO. OF 1-4
NO. OF ALL
POPULATION
FAMILY
OTHER
STRUCTURES
STRUCTURES
7. FOR FEMA REGIONAL OFFICE USE ONLY
1. FEMA REGIONAL OFFICE
2. NAME OF CONTACT
3. TELEPHONE NO.
4. LEVEL OF 44 CFR 60.3 REGULATION ADOPTED
5. CHECK APPROPRIATE BOX:
(Check one)
EMERGENCY PHASE
REGULAR PHASE
60.3(a)
60.3(b)
60.3(c)
60.3(d)
60.3(e)
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 81-64, APR 06
REPLACES ALL PREVIOUS EDITIONS
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