AFFIDAVIT
I/We, _____________________________, affirm the following:
1. I/We own real property at ___________________________________, and make this Affidavit in connection with the purchase of that real property by [Community] in conjunction with a property acquisition project funded under the Federal Emergency Management Agency’s (FEMA’s) Hazard Mitigation Grant Program (HMGP).
2. I/We have received the following structural repair assistance funds as the result of flooding that occurred on ____________________.
Flood Insurance
$

Disaster Housing Program Grant
$

State Individual & Family Grant (IFG)
$

Hazard Minimization Grant
$

Small Business Administration (SBA) Loan
$

Other:

$


3. I/We have received no other Federal assistance funds for structural repair other than that set forth above.
4. I/We can produce receipts for structural repair in the total amount of $_______________.  Attach receipts.



Property Owner Signature

Date



Property Owner Signature

Date

Notary Public
Seal



Signature

Date
My commission expires

.



Form II-10, Affidavit



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