DEPARTMENT OF HOMELAND SECURITY 
FEDERAL EMERGENCY MANAGEMENT AGENCY 
APPLICATION FOR PARTICIPATION IN THE NATIONAL FLOOD 
INSURANCE PROGRAM

O.M.B. NO. 1660-0004 
Expires March 31, 2011

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 data needed, and completing, and submitting the form. You are not required to submit to this collection of information unless 
it displays a valid OMB control number. 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, and Paperwork 
Reduction Project (1660-0004). NOTE: Do not send your completed form to this address. 


(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 (Official, if different from above, with overall responsibility for implementing program)) 
(E-MAIL ADDRESS) 
(TELEPHONE NO. (Include area code)) 
(ADDRESS (Street or box no., city, state, zip code)) 
(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


(AREA IN ACRES) 
(POPULATION) 
(NO. OF 1-4 
FAMILYSTRUCTURES) 
(NO. OF ALL
OTHER STRUCTURES) 
6. ESTIMATES OF TOTALS IN ENTIRE COMMUNITY


(POPULATION) 
(NO. OF 1-4 
FAMILYSTRUCTURES) 
(NO. OF ALL
OTHER STRUCTURES) 
7. FOR FEMA REGIONAL USE ONLY


(1. FEMA REGIONAL OFFICE) 
(2. NAME OF CONTACT) 
(3. TELEPHONE NO.) 
4. LEVEL OF 44 CFR 60.3 REGULATION ADOPTED (Check one)

60.3


(Level of 44 C, F, R, 60.3 regulation adopted. If 60.3, check here.) Unchecked
60.3(b)


(Level of 44 C, F, R, 60.3 regulation adopted. If 60.3, b, check here.) Unchecked
60.3(c)


(Level of 44 C, F, R, 60.3 regulation adopted. If 60.3, c, check here.) Unchecked
60.3(d)


(Level of 44 C, F, R, 60.3 regulation adopted. If 60.3, d, check here.) Unchecked
60.3(e)


(Level of 44 C, F, R, 60.3 regulation adopted. If 60.3, e, check here.) Unchecked
5. CHECK APPROPRIATE BOX:

EMERGENCY PHASE


(If emergency phase, check here.) Unchecked
REGULAR PHASE


(If regular phase, check here.) Unchecked
(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, MAR 08