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HomeMy Public PortalAboutMILLER AV_1403.pdfFLOOD POLICY DEULARNFIONS A S S U R A N T® American Bankers Insurance Company of Florida Scottsdale, AZ 85261-4337 Standard Polic Pre -FIRM Subsidized Type: Revised Declaration y Policy Period: 07/07/2018 07/07/2019 For payment status, calls (800) 423-4403 Original New Business Effective Date: 07/07/2005 These Declarations are effective Reinstatement Date: as of: 07/07/2018 at 12:01 AM Form: Dwelling Producer Name and Mailing Address: DALY INSURANCE 513 E OGLETHORPE AVE STE E SAVANNAH, GA 31401-4141 NFIP Policy Number: 6005443830 Agent/Agency #: OEv461 Reference #: 70163 -18348 - 000 Phone#: (912)352-1400 Property Location: 1403 MILLER AVE TYBEE ISLAND, GA 31328-9684 Primary Residence: Y Premium Payor: Insured Insured Name and Mailing Address: LOVATO, PATRICK HENRY LOVATO, PAMELA SUE 1403 MILLER AVE TYBEE ISLAND, GA 31328-9684 NAIC Number: 10111 Processed by: Flood Service Center P.O. Box 8695 Kalispell MT 59904-8695 Building Description: Single Family One Floor Slab On Grade Flood Risk/Rated Zone: AE Current Zone: Community Number: 13 5164 0326 F Community Name: TYBEE ISLAND, CITY OF Grandfathered: Pre -Firm Construction Program Type: Regular Newly Mapped into SFHA: Elev Dim N/A Elevated Building. N Includes Addition(s) and Extension(s) Replacement Cost: $200,000 Number of Units: 1 afies=<_=...::__:::;:: --]educt Discouxlt Suh Total Premium Calculation 'tilld-121'-_` 250,000 1.040 / .950 5,000 170 2,259.00 l�reiniuTu SuhLnti€il; 2,564.00 f3IlTitS_ 25,000 1.310 / 1.710 2,000 23 305.00 Multiplier: Lowest Floor Only Above - vu Ground Level X"C Premium. 55.00 CRS i7ismun0,: 657.00 Reserve Fund Aasmt: 296.00 HFUA Surchiirge: 25.00 Federal Policy Fee: 50.00 Pr€tbatian Surcharge: .00 Coverage Limitations May Apply. See Your Policy Form for Details. First Mortgage: Central Loan Administration ISAOA/ ATIMA PO Box 202028 Florence, SC 29502-2028 Loan#: 0095062725 Loss Payee: Second Mortgage: Disaster Agency: Amount: im, Paid: 452.00 2,343.00 U.3.DEPARTMENT OFHOMELAND SECURMY ELEVATION CERTIFICATE FEDERAL EMERGENCY MANAGEMENT AGENCY GMB No. 1660-0008 Yariarra/ flacxt Insurance ProgramImportant: Read the instructions on pages 1-9. ? Expiration Date: July 31, 2015 SECTION A - PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Buitdino Owner's Name KEITH L GAY Policy Number. A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Company NAIC Number: 1403 MILLER AVENUE ISLAND ZIP Code 3132E A3. Property Description (Lot artd Block Numbers, Tax Parcel Number, Legal Description, etc.) LOTS 185 & 186, WARD 4, TYBEE ISLAND TAX PARCEL 4-0007-21-017 A4. Building Use (e.g., Residential. Non -Residential, Addition, Accessory, etc,) RESIDENTIAL A5. Latitude/Longitude: Lat, 31-59.44.61 Long. 000-51-04.60 Horizontal Datum: ❑ NAD 1927 N NAD 1983 AS. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7, Building Diagram Number 1A A8, For a building with a crautspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) NIA sq ft a) Square footage of attached garage WA sq ft b) Number of permanent flood openings in the crawispace b) Number of permanent Rood openings in the attached garage or enclosures) within 1.0 foot above adjacent grade WA within 1.0 foot above adjacent grade NIA c) Total net area of Rood openings in A8.b NIA sq in c) Total net area of flood openings in A9.4 NIA sq in d) Engineered flood openings? ❑ Yes ® No d) Engineered flood openings? ❑ Yes ® No SECTION 8 - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1, NFIP Community Name & Community Number 82. County Name B3. State j CITY OF TYBEE ISLAND 135164 CHATHAM LGEORGIA B4. Map/Panel Number B5. Suffer B6. FIRM Index Date 87. FIRM Panel i 88. Food I B9. Base Flood Elevation(s) (Zone 13051C 0326 i F 9/2612008 Effeetme(Revised Data l Zone(s) A0, use base flood depth) i 9/26/2008 AE 12.0' , L_ BID. Indicate the source of the Base Flood Elevation (BFE) data or base Rood depth entered in Item 89. O FIS Profile 0 FIRM ❑ Community Determined 0 OthedSource: 811. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 0 NAVD 1986 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (GPA)? Q Yes ® No Designation Date: ❑ CBRS ❑ OPA SECTION C - BUILDING, ELEVATION INFORMATION (SURVEY REQUIRED) Cl. Building elevations are based on: ❑ Construction Drawings' ❑ Building Under Constructdon` Finished Construction f1 new Elevation Certificate will be required when construction of the building is complete. C2. Elevations --Zones Ai A30, AE, AH. A (with BFE), VE, Vi V30, V (with BFE), AR, AR/A, ARiAE, AR/Ai-A30. AR/AH, ARIAO. Complete Items C2. a -h below according to the building diagram specified in Item A7. in Puerto Rico only, enter meters. Benchmark utilized: GPS ESTABLISHED ISHED Vertical Datum: NAVD 1988 Indicate elevation datum used for the elevations in items a) through h) below. Q NGVD 1929 N NAVD 1988 0 Other/Source: Datum used forbuifding elevations must be the Same as that used for the BFE. Check the measurement used. a) Top of bottom floor (including basement, crawtspace, or enclosure floor) &.Q €est Q meters b) Tot) of the next higher floor LJ18 feet C) Bottom of the lowast horizontal structural member (V Zones only)❑ ❑ feet ❑ meters © meters d) Attached garage (top of slab) e) Lowest elevation of machine NIA ❑ feet ❑ meters orservicing ser m n t the building (Describe '1' location type of equipment and location in Comments) 7.0 gj feet ❑ meters f) Lowest adjacent (finished) grade next to building (LAG) g) Highest adjacent (finished) grade next to building (HAG)-A.7 H 4.7AG) ® feet ❑ meters h) Lowest adjacent grade of (Qwest elevation of deck or stag s, including structural 4 S ® feet Q teeters support 4.7 feet Q meters SECTION D -SURVEYOR, ENGINEER, OR ARCHITECT 7h' CERTIFICATION rs cerGficahon luto Ise signed and sealed by a land surveyor, engineer, or architect authorized by law to certify y elevation information. nformation l c&ririy that the irrrorm&tion on this Genii fe represents my best effWs to interpret the data ,vagak/a 1 understand that any rats& statement may be punishable by fine or imprisonment under Is U.S. Code, Section 1001. ® Check here if coimments are provided on back of form. Check here if attachments. Were latitude and foiigrtude in Section A provided by a C7 Cediffer's Name MICHAEL .d. GARDNER Title LAND SURVEYOR Address 120 signature LmA Form 086-0-33 (7112) licensed land surveyor? ® Yes Q No License Number GA. RLS 2285 Company Name dAiCHAEL J. GARDNER, LAND SURVEYOR k,rly UAHL IEN CITYstate GA -ZIP Cade 31408 ". kv rurullzulb Telephone 91241-0479 (CELL) See reverse side for Continuatiort, Replaces all previous editions. t:LCVAIIUN UI=Kt11-I(;A I E. page 2 IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) of P,0- Route and Box No. Policy Number 1403 MILLER AVENUE t7j City TYBEE ISLAND State GA ZIP Code 31328 Company NAIC Number: SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for (1) community official, (2) insurance agent/company, and (3) building owner, Comments C2 (a) Elevation of Lowest AC Pedestal =7JY. AC Pedestal is located on Right Rear of Residence. NOTE: Elevation of AC Pedestal at Left Side of Residence = 87. NOTE: Finish Floor of Unattached Garage = 4Z. NOTE: Residence Constructed in 1960 Prior to FEMA REQUIREMENTS. PROJECT NO: KLGAY, 10/07120 01), F , MJG, 2015. -C!. PG 02 Signature —'I Date 10/0712015 SECTION E - EfUILQ1fiG ELEVATION INOCIRMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT EIFE) For Zones AO and A (without EIFE), complete Items EI -ES. If the Certificate is intended to support a LOMA or LOMR-F request. complete Sections A, B. and C. For items El -E4, use natural grade. if available. Check the measurement used, In Puerto Rico only, enter meters. El. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above of below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (including basement crawispace. or enclosure) is _ 171 feet 0 meters [I above or 0 below the HAG. b) Top of bottom floor (including basement, crawlspace, or enclosure) is _ 0 feet 0 meters 0 above or 0 below the LAG. E2. For Building Diagrams " with permanent flood openings provided in Section A items 8 and/or 9 (see pages 8-9 of Instructions), the next higher floor (elevation C2.b in the diagram) of the building is [] feet [] meters 0 above or 0 below the MAG_ E3. Attached garage (top of stab) is �_ 0 feet 0 meters 0 above or 0 below the HAG. E4, Top of platform of machinery arWor equipment servicing the building is 0 Let 0 meters C] above or 0 below the MAG. E5. Zone AD ony, If no flood depth number is available, is the top of the bottom floor elevated in accordance with the community floodplain management ordinance? 0 Yes 0 No 0 Unknown, The local official must certify this information in Section G. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property owner or owner's authorized representative who completes Sections A, 8, and E for Zone A (without a FEMA -issued or community -issued BFE) or Zone AD must sign here. The statements in Sections A, 8, and E are correct to the best of my knowledge. Property Owners or Owners Authorized Representative's Name Address city State ZIP Code Signature Date Telephone Comments Check here if attachments. SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local officiatwho is authorized by law or ordinance to administer the communiVs floodptain management ordnance can complete Sections A. 8, C WE), and G of this Elevation Certificate. Complete the applicable item(s) and sign below. Check the measurement used in Items G8 -G10. In Puerto Rico only, enter meters. 01.171 The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architectwho Is authorized by law to certify elevation information. (indicate the source and date of the elevation data in the Comments area below.) G2,0 A community official completed Section E for a building located in Zone A (without a FEMA -issued or community4ssued OFE) or Zone AO. G3- 0 The fallowing information (items G"10) is provided for community floodplain management purposes, 1 G4, Permit Number C5, Date Permit issued i G6, Date Certificate Of Compfiance/Ocrupancy Issued G7- This permit has been issued for. 13 New construction ❑ Substantial Improvement G8 Elevation Of as -built lowest floor (including basement) of the buitcling: 0 feet 0 meters Datum Gg. SFE Of (in Zone AD) depth of flooding at the building site: 0 filet 0 meters Datum G10. Community's design flood elevation: [] feet n meters Datum Local Official's Name T -die Community Name Telephone Signature Date Check here if attachments, FEMA d=orm 086-0-33 (7112) Replaces all previous editions. ELEVATION CERTIFICATE, page 3 Building Photographs See Instructions for Item A6. IMPORTANT: in these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address (including Apt., Unit, Suite, aridlor Bldg. No.) or P O. Route and Box No. Policy Number. 1403 MILLER AVENUE City TYBEE ISLAND State GA ZIP Code 31328 Company NAtC Number. If using the Elevation Certificate to obtain NFIP flood insurance, affix at feast 2 building photographs below according to the instructions for Item A6. identify all photographs with date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View," When applicable, photographs must show the foundation with representative examples of the flood openings or vents, as indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page. I FRONT VIEW REAR VIEW I LEFT VIEW RIGHT VIEW FEMA Form 486-0-33 (7112) - - Reptaces all previous editions. November 2018 FEMA Flood Mitigation Assistance Grant Program STRUCTURE ELEVATION DOCUMENTATION PACKAGE The Flood Mitigation Assistance (FMA) program makes available federal funds to State, Local and Tribal Governments to take critical mitigation measures to reduce the risk of loss of life and property. The City of Tybee Island is developing a competitive grant application to elevate eligible residential structures through the FMA program. Structure elevation projects must be technically feasible, cost effective, and compliant with environmental and historic preservation regulations. Homeowners must have an active Flood Insurance policy through the National Flood Insurance Program. INSTRUCTIONS • Complete all enclosed paperwork in the Documentation Package. • Compile necessary documentation, listed in the Application Package Checklist. • Return the completed Documentation Package to George Shaw, Director of Community Development, at 403 Butler Avenue, Tybee Island, GA 31328 or by email at TybeeFMA@gmail.com. DEADLINES AND IMPORTANT DATES: • Documentation Package Deadline: Thursday, November, 29 2018. o MUST PROVIDE PROOF OF FLOOD INSURANCE. • Engineering Assessment for New Applicants (not submitted under HMGP): December 3 - 16th. NEXT STEPS • The City of Tybee Island will review all submitted Documentation Packages for eligibility and project prioritization in accordance with the Federal Emergency Management Agency (FEMA), the Georgia Emergency Management and Homeland Security Agency (GEMA) funding guidelines. o Applicant must have a Flood Insurance Policy and must be considered a Repetitive Loss property or Severe Repetitive Loss Property. • Once eligibility is established, an engineering professional will visit structures to evaluate technical feasibility, complete an Elevation Certificate (if necessary), estimate project costs, take site photographs, and develop a scope of work. • The City of Tybee Island is in the process of developing the FMA program pre -application. Once approved by GEMA, the City will submit the FMA application to FEMA by December 3, 2018. • Please address any questions that you may have to TybeeFMA@gmail.com November 2018 DOCUMENTATION PACKAGE CHECKLIST Please fill out the enclosed paperwork and attach all required documentation. Ensure that all information included is accurate and complete for your application to be considered during this cycle. Documentation Packages are due by Thursday, November 29th, 2018. Once completed, this package can either be submitted in person to the Planning & Zoning Department at 403 Butler Avenue or online as a PDF to TybeeFMA@gmail.com. REQUIRED PAPERWORKTO BE RETURNED ❑ Notice of Voluntary Interest ❑ Acknowledgment of Conditions (MUST BE NOTARIZED) ❑ Privacy Act Release ❑ Declaration and Release Form ❑ Duplication of Benefits ❑ Voluntary Consent to Enter Property ❑ Voluntary Participation Form ❑ PROOF OF FLOOD INSURANCE (REQUIRED FOR PARTICIPATION) ❑ Elevation Certificate (if you don't have one, an engineering professional will assess your home and provide one on your behalf) ❑ Any documentation of prior flood damage that you believe to be useful **Please note that this homeowner meeting does not serve as a contractual agreement and trere is no guarantee that your property will be mitigated through this process. However, all homeowners who are interested in participating must provide necessary documentation for eligibility review Notice of Voluntary Interest City of Tybee Island, Georgia Structure Elevation Project Homeowner Interest Sign-up Sheet and Voluntary Interest Notice Please complete this form if you are interested in exploring further options for reducing your flood losses. Signing this does not commit you to any action. Please Print clearly. Property Address )-�1a.3 1-n,,l Owner(s) Mailing Address: —<CLO" 2 Owner(s) Name(s): �17Gf k I fin. o, �GLYh-2 k,l..C) �i Contact Telephone Number: - 1?9S — W72-T— Owner(s) Email Address: k /O IQ-/- Signature Owner(s) Signature 1/- Zv-/J Date /l -a x-14' Date 6- 31 3..) The local government is required by FEMA to inform you that your participation in this project for structure elevation is voluntary. Acknowledgement of Conditions For Mitigation of Property in a Special Flood Hazard Area With FEMA Grant Funds Property Owner Street Address / D 3 /i%i /�� f✓� City ,State G,4 Zip Code v/3sZd' Deed datb 3l �% / J , Recorded A�3 /.;;,-o 7 Tax map , block i �-S/no Wb-9 , parcel /. 0oo 7 -2_1-6 �7 Base Flood Elevation at the site is feet GVD). Map Panel Number /,3os/ C d 3d , effective date As a recipient of Federally -funded hazard mitigation assistance under the Flood Mitigation Assistance Program, as authorized by 42 U.S.C. §4104c the Property Owner accepts the following conditions: That the Property Owner has insured all structures that will not be demolished or relocated out of the SFHA for the above-mentioned property to an amount at least equal to the project cost or to the maximum limit of coverage made available with respect to the particular property, whichever is less, through the National Flood Insurance Program (NFIP), as authorized by 42 U.S.C. §4001 et seq., as long as the Property Owner holds title to the property as required by 42 U.S.C. §4012a. 2. That the Property Owner will maintain all structures on the above-mentioned property in accordance with the flood plain management criteria set forth in Title 44 of the Code of Federal Regulations (CFR) Part 60.3, The Official Code of Georgia Annotated. a. C.G.A. Section 8-2-20(9)(B), and any local ordinance standards as long as the Property Owner holds title to the property. These criteria include, but are not limited to, the following measures: i. Enclosed areas below the Base Flood Elevation will only be used for parking of vehicles, limited storage, or access to the building; ii. All interior walls and floors below the Base Flood Elevation will be unfinished or constructed of flood resistant materials; iii. No mechanical, electrical, or plumbing devices will be installed below the Base Flood Elevation; and iv. All enclosed areas below Base Flood Elevation must be equipped with vents permitting the automatic entry and exit of flood water. For a complete, detailed list of these criteria, see City/County Ordinance attached to this document. 3. The above conditions are binding for the life of the property. To provide notice to subsequent purchasers of these conditions, the Property Owner agrees that the City/County will legally record with the county or appropriate jurisdiction's land records a notice that includes the name of the current property owner (including book/page reference to record of current title, if readily available), a legal description of the property, and the following notice of flood insurance requirements: "This property has received Federal hazard mitigation assistance. Federal law requires that flood insurance coverage on this property must be maintained during the life of the property regardless of transfer of ownership of such property. Pursuant to 42 U.S.C. §5154a, failure to maintain flood insurance on this property may prohibit the owner from receiving Federal disaster assistance with respect to this property in the event of a flood disaster. The Property Owner is also required to maintain this property in accordance with the flood plain management criteria of Title 44 of the Code of Federal Regulations Part 60.3, The Official Code of Georgia Annotated. O.C.G.A. Section 8-2-20(9)(6), and any pertinent local ordinance." 4. Failure to abide by the above conditions may prohibit the Property Owner and/or any subsequent purchasers from receiving Federal disaster assistance with respect to this property in the event of any future flood disasters. If the above conditions are not met, FEMA may recoup the amount of the grant award with respect to the subject property, and the Property Owner may be liable to repay such amounts. This Agreement shall be binding upon the respective parties' heirs, successors, personal representatives, and assignees. HOMEOWNER/PROPERTY OWNER SIGNS HERE: Name of Property Owner: i Q4 A Lffd AV STATE OF GEORGIA COUNTY OF a� The foregoing instrument was acknowledged before me this, q day of NOV , cD 8 by who is (11) personally known to me or (❑) has produced as identifi do A Y PU450 SEAL: LISA L. SCHAAF NOTARY PUBLIC, CHATHAM COIiR GEORGIA My COMOISSION EXPIRES. -APRIL 2, 2019 Printed Name of Notary Privacy Act Release I/We, the undersigned, hereby grant my/our permission for the City of Tybee Island to publish, through public notice, the location of my real property which is being considered for an elevation project by the City of Tybee Island. This information will be used to notify the public that FEMA and the State are considering a mitigation action that may include my property under Section 404 (HMGP) of the Stafford Act, as amended, the Flood Mitigation Assistance Program, the Pre -Disaster Mitigation (PDM) Program, and/or HUD programs. Further, I/we hereby grant FEMA and the State of Georgia permission to disclose flood insurance coverage and claim information, and information about disaster assistance payments received by me/us, to officials of the City of Tybee Island for the purpose of aiding in their planning and decision-making regarding mitigation or assistance actions affecting my property. This information will be used for this purpose only and will not be made public. EW Date � , J, zk� z Print 0"6f's Name ' igned ��G ,5,,l T- 977 V Social Security Number Address of Property CW, State, ZIP Print Owner's Name Signed &t 8' 78ala > Social Security Number If applicable: Flood Insurance Policy Number: lo0c��5L,��p�ca� Insurance Agent's Phone Number: Insurance Provider/Company: 41"a ato ay,�ikPrj Insurance Company's 5 -digit Company Code: Duplication of Benefits The Federal Emergency Management Agency (FEMA) has adopted a policy that prohibits duplication of benefits in the Hazard Mitigation Assistance Program that includes Flood Mitigation Assistance grants. The policy was developed in response to federal regulations that dictate the use of the primary funds used to mitigate property. FEMA provides the following specific instructions in the Hazard Mitigation Assistance Program Guidelines for mitigation projects. In the administration of FMA grants, FEMA and the grantee should avoid any duplication of benefits with other forms of assistance. FEMA's policy on duplication of benefits for individuals and families is mandated by Section 312 of the Stafford Act and is set forth in 44 CFR 206.191. This Section of the FEMA regulations delineates a delivery sequence establishing the order in which the disaster relief agencies and organizations provide assistance to individuals and families. Programs listed later in the sequence are responsible for ensuring that they do not duplicate assistance which should be provided by a program listed earlier on the list (the program with primary responsibility). In the case of flood -damaged property programs (Section 1362, Section 404, etc.), they are not listed in the delivery sequence, and therefore are positioned after the eight listed programs. This means that all eight programs listed in the sequence at 44 CFR 206.191 (d) are "primary programs" in relation to mitigation grant programs. The Flood Mitigation Assistance Program is required to ensure that it does not duplicate assistance which should be provided by any of the eight primary assistance programs. Certification of Funds Used Receipt of or pending receipt of the following benefit amounts must be disclosed to the State of Georgia 1. SBA Loans - A property owner who has an SBA loan on the property being acquired will either be required to re ay the loan to SBA, or roll it over to a new property at closing. Yes ❑ No 2. Flood Insurance for Structure Repairs - That portion of a flood insurance payment that a property owner has received or is eligible to receive intended to cover structural repairs to the property being acquired will be deducted from the purchase price of the property being acquired. If flood insurance funds have been reinvested into repairs to the property, this amount will not be deducted. Proof of reinvestment can be supplied through receipts for materials and/or labor, or through on-site verification. Amount reinvested is $ 3. Increased Cost of Compliance -The NFIP Increased Cost of Compliance (ICC) claim payment from a flood event may be used to contribute to the non -Federal cost -share requirements so long as the claim is made within the timelines allowed by the NFIP. ICC payments can only be used for costs that are eligible for ICC benefits; for example, ICC cannot pay for property acquisition, but can pay for structure demolition or relocation. In addition, Federal funds cannot be provided where ICC funds are available; if the ICC payment exceeds the required non -Federal share, the Federal funding award will be reduced to the difference between the cost of the activity and the ICC payment. Have you received ICC payments? IJ o If so, how much ICC funds have you received? — Do you plan on receiving ICC payment? ,y{ J If so, how much ICC funds do you plan on receiving? 4. FEMA Individual Family Grant and Emergency Minimal Repair Grant (EMR) - That portion of an IFG grant that a property owner has received or is eligible to receive intended to cover structural repairs to the property being acquired will be deducted from the purchase price of the property. Additionally, grants received from FEMA as part of Temporary Housing Assistance Program to quickly repair or restore owner -occupied primary residences to habitable and safe condition will be deducted from the purchase price of the property. If the funds have been reinvested into repairs to the property, this amount will not be deducted. Proof of reinvestment can be supplied through re cei is for materials and/or labor, or through on-site verification. Amount received: ' 5. FEMA Disaster Housing - FEMA Disaster Housing money received by the property owner will not be deducted if the property owner has used the grant for housing related expenses. These can include: transient accommodations while an existing home is being elevated or relocated; combining it with other funds to make more substantial home repairs; minor home repairs made to make a home more livable prior to a buyout offer; down payments toward the purchase of a new home; moving expenses; closing costs; insurance, and deposits. Amount received: 0 Owner Name: Property Address: 441 &_212,w 1 hereby certify that the SBA Loans, Flood Insurance for Structure Repairs, FEMA Individual and Family Grant, Emergency Minimal Repair Grant (EMR) and FEMA Disaster Housing benefits defined above have been accurately reported and that the not use or the purpo%�e tified above have bee Ily disclosed. 7 Signed Signed Date DEPARTMENT OF HOMELAND SECURITY O.M.B. No. 1660-0002 Federal Emergency Management Agency Expires February 28, 2021 DECLARATION AND RELEASE PAPERWORK BURDEN DISCLOSURE NOTICE reporting burden for this data collection is estimated to average 2 minutes per response. The burden estimate includes the time for reviewing instructions, ling existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, .ment of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472-3100, Paperwork Reduction It (1660-0002). NOTE: Do not send your completed form to this address. PRIVACY ACT STATEMENT ORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records within this system under the authority of the Robert T. Stafford Disaster and Emergency Assistance Act (the Stafford Act), Pub. L. No. 93-288, as amended (42 U.S.C. §§ 5121-5207); 6 U.S.C. §§ 776-77, 795; the Debt lion Improvement Act of 1996, 31 U.S.C. §§ 3325(d), 7701(c)(1); the Government Performance and Results Act, Pub. L. No. 103-62, as amended; anization Plan No. 3 of 1978; Executive Order 13411, "Improving Assistance for Disaster Victims," August 29, 2006; and Executive Order 12862 "Setting ner Service Standards," September 11, 2003, as described in this notice. :IPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administrating financial assistance under a entially-declared disaster. Additionally, information may be reviewed internally within FEMA for quality assurance purposes and used to assess FEMA's ler service to disaster assistance applicants. FEMA collects the social security number (SSN) to verify an applicant's identity and to prevent a duplication of ROUTINE USE(S): FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their disaster assistance files outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, including pursuant to routine uses published in DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records, 78 Fed. Reg. 25,282 (Apr.30, 2013) and upon written request, by agreement or as required by law. FEMA may share the personal information of non -citizens, as described in the following Privacy Impact Assessments: DHS/ FEMA/PIA-012(a) Disaster Assistance Improvement Plain (DAIP) (Nov. 16, 2012); DHS/FEMA/PIA-027 National Emergency Management Information System - Individual Assistance (NEMIS-IA) Web -based and Client -based Modules (June 29, 2012); DHS/FEMA/PIA-015 Quality Assurance Recording System (Aug. 15, 2014). FEMA may share your personal information with federal, state, tribal, local agencies and voluntary organizations to enable individuals to receive additional disaster assistance, to prevent duplicating your benefits, or for FEMA to recover disaster funds received erroneously, spent inappropriately, or through fraud. CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: The disclosure of information, including the SSN, on this form is voluntary; however, failure to provide the information requested may delay or prevent the individual from receiving disaster assistance. In order to be eligible to receive FEMA Disaster Assistance, a member of the household must be a citizen, non -citizen national or qualified ali of the United States. Please read the form carefully, sign the sheet and return it to the Inspector, and show him/her a current form photo identification. Please feel free to consult with an attorney or other immigration expert if you have any questions. I hereby declare, under penalty of perjury that (check one): I am a citizen or non -citizen national of the United States. I am a qualified alien of the United States. I am the parent or guardian of a minor child who resides with me and who is a citizen, non -citizen national or qualified alien of the United States. Print full name and age of minor child: By my signature I certify that: " Only one application has been submitted for my household. " All information I have provided regarding my application for FEMA disaster assistance is true and correct to the best of my knowledge. " I will return any disaster aid money I received from FEMA or the State if I receive insurance or other money for the same loss, or if I do not use FEMA disaster aid money for the purpose for which it was intended. I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain disaster aid, it is a violation of federal and State laws, which carry severe criminal and civil penalties, including a fine up to $250,000, imprisonment, or both (18 U.S.C. §§ 287, 1001, and 3571). 1 understand that the information provided regarding my application for FEMA disaster assistance may be subject to sharing within the Department of Homeland Security (DHS) including, but not limited to, the Bureau of Immigration and Customs Enforcement. I authorize FEMA to verify all information given by me about my property/place of residence, income, employment and dependents in order to determine my eligibility for disaster assistance; and authorize all custodians of records of my insurance, employer, any public or private entity, bank financial or credit data service to release information to FEMA and/or the State upon request. !v INSPECTOR ID # SIGNATURE FEMA APPLICATION # ADDRESS OF DAMAGED PROPERTY CITY DATE OF BIRTH DISASTER # STATE FEMA FORM 009-0-3 REPLACES ALL PREVIOUS EDITIONS Voluntary Consent to Enter Property Our records indicate that you have elected to apply for the Federal Emergency Management Agency's Flood Mitigation Assistance (FMA) Program. As part of the application development process, a qualified professional must develop a rough cost estimate and assess the structure to ensure that implementing the elevation project is technically feasible. The purpose of this document is to obtain homeowner consent for contracted staff to enter the property located at /;P� /k - for the purposes stated herein. The City of Tybee has selected a team of contractWs to provide technical assistance and support for the grant application development process. The purpose for this site visit is to take exterior structure and property photographs as well as necessary measurements to perform a feasibility study and to gather information for cost -estimating and scoping purposes. It is not necessary at this time to enter the home. If signed and returned, staff may be assessing properties as early as the week of December 3rd, 2018. Jl u will be notified via details., W;� perty Owner Signature I and/or the phone number you provided with additional 721 101147-6 ,2 a✓Ar11k/ rint Name Date Witness Si ature l SGS - JC�/�Q�AJa✓.�1,1 g Print Name Date Voluntary Participation Form ELEVATION FEMA Flood Mitigation Assistance (FMA) INSTRUCTIONS: Please fill out this form in its entirety for each structure you wish to be considered for mitigation. Signing this form does not commit y9p or the community to any action. PROPERTY OWNER: "�t /Zo� ✓ `4 Phone Number: _ ?(V jVS-<1-7 4.i CO-OWNERS) : "�a' �� �V Gt �O Email Address: 7 SjOVG+� r� '. Cp— Property Address: 1V0 -g1n"11& '4ye Mailing Address: �tyh-L HOUSEHOLD INFORMATION - Please provide the following information about your household. Total # of persons who reside in your household: PROPERTY INFORMATION- At time of Flood Body of water causing Flooding: 66t Gk--ir y¢i For each of the following categories, please circle the features that apply. STRUCTURE USE: STRUCTURE TYPE: FOUNDATION TYPE: Single Family Basement Y N Outside Entrance Y N BUILDING TYPE: Wood wner Occupied -Primary wner ccupie - econ ary -4 Fam' Finished Y N Partial Y N 1. Masonry (Brick) Rental Multi (5+) Crawl Space Y N Stone Vacant Lot Manufactured Elevated on iers/columns/posts/piles emen Other (Explain) Vacant Land lab on Grade Other Other (Explain) ac t an Other (Explain) TAX Parcel #: - dao 7- -2/ 01 7 Total Living Area in Sq Ft. (All floors) Heated and Cooled Sq Ft.: -2 S (o Original Date of Construction: Number of Stories above ground:_ Non -living area Sq Ft.: Is the property contaminated with hazardous waste (lead-based paint, asbestos, etc.)? _Yes ?' No Do you have an Elevation Certificate.' (�1 N Is the structure an historic property? _ Yes _! No Repetitive Loss/ Severe Repetitive Loss # f NSURANCE INFORMATION - Please provide the following information. Do you currently have Flood Insurance? N Insurance Company:_ co*n 7 Flood Policy #: &0d S Please prov►d past flood claim information below. Provide details of historical losses on the next page. Date: cs -) Claim Amount: $ 3 b I`. /S' Date: Claim Amount: $ f i 6 7, /& Date: Claim Amount: $ By submitting this form, I affirm the following: Date: Claim Amount: $ • That the statements on this form are true and complete to the best of my knowledge; • That I/we own the property located at /403 /720f, • That the modification of this property under a FEMA Hazard Mitigatio Assistance Program is voluntary in nature, that I am under NO obligation to participate, and that I may drop out of the application process at any time; • That I currently intend to participate; • That I understand my submittal of this form and associated documentation only indicates my willingness to participate in the program and does not guarantee that my property will be mitigated through the program or by the community. • If approved for a grant, I understand that I maybe required to pay a match amount of up to 10%-25f the total projec cost to mitigate my home. I affirm that I have the resources to meet the cost -share and cost-reim;Vement requirements. ) NAME: 'PAM/ CK 1� L(f ✓� DATE: ;!2I A�1 pil�j k' SIGNATURE: WITNESS:/JQ Gf1q DATE: 1 %UPVf� SIGNATUR - Voluntary Participation Form ELEVATION FEMA Flood Mitigation Assistance (FMA) HISTORICAL LOSS INFORMATION: Please attach any photos or historical loss documentation that may be helpful. I affirm that, to the best of my knowledge, the following information istrue and complete. NAME: R LOdATb DATE: —� l — �d SIGNATURE: ' 10 -a T - 2Gt � FIRST FLOOD EVENT Date and Name jif known) of Event: R Source of Flooding (Body of Water): Please list the back up documentation source: AM//i� Back up documentation attached? —Yes _ No tJ Depth of flooding: reef ee j Duration of flooding: I / Damages (_ Estimated YKnown): $ `A7 Displaced from home: r- Yes No How long? � Types of Damages: / eadle, Notes: SECOND FLOOD EVENT Date and Name (if known) of Event: Source of Flooding (Body of Water): Backup documentation attached? —Yes i�No Please list the back up documen tation source: Duration of flooding: =M Displaced from home: Yes No How long? Types of Damages: �✓ �ty ���/"" ` l%� bd Notes: Depth of flooding: -1 1 73i 7.1 1000 Damages( Estimated _ Known): $ 5 C)C) a THIRD FLOOD EVENT Date and Name (if known) of Event: Source of Flooding (Body of Water): Please list the back up documentation source: Duration of flooding: Displaced from home: Notes: Back up documentation attached? _ Yes _ No Depth of flooding: Damages (_ Estimated _ Known). $ Yes No How long? Types of Damages: NOVEMBER 2018 FLOOD MITIGATION ASSISTANCE (FMA) Frequently Asked Questions (FAQ) What is the difference between this application (FMA) and the HMGP application submitted earlier this year? The two programs differ in two major ways: 1. Flood Insurance: The owner of each structure submitted in this application must have an active flood insurance policy that pre -dates October 1, 2018. 2. Homeowner Cost Share: It is lower for FMA projects: a. For RL properties, FEMA covers 90% of the project and the homeowner covers the remaining 10%. b. For SRL properties, FEMA covers 100%. c. For Non-RL/SRL, FEMA covers 75%. How do I know if my home is a Repetitive Loss (RL) or Severe Repetitive Loss (SRL) Property? If you are uncertain as to whether your property is deemed as a RL or SRL property, please contact George Shaw with the City of Tybee Island at 912-472-5031 for confirmation. Due to the sensitive nature of this private information, it will not be shared publicly or online. But what about Duplication of Benefits, can I still apply to this program even though my property was submitted under the HMGP application? YES! As the funding decision for the HMGP application has not yet been made, homeowners who are eligible for this program should apply. If homeowners who applied to both programs are approved under the HMGP program before the FMA funding decision is made, we will work with them on a case-by-case basis to determine the best way forward. How will mitigation affect my flood insurance rates? As risks change, insurance premiums may also change to reflect those risks. Please check with your insurance agent for details. If I elevate my home, do I have to bring everything else up to code? If the elevation project qualifies as a substantial improvement, the structure may have to be brought into compliance with all applicable codes and standards, not just those that apply to floodplain management. Check with the local building department for additional details. My house is currently on the market, but I am interested in participating. What if it sells? If a home is sold during application review and the proposed project is awarded, then the new property owner will be consulted for participation in the grant. All participation is voluntary. What documents am I required to submit and retain? It is preferable that you complete all forms in the Document Package to the best of your ability and retain copies of all documents. Some forms will require notarization. What if something unexpected happens during project implementation? Notify the City immediately of any potential changes in project performance or anticipated completion. NOVEMBER 2018 FLOOD MITIGATION ASSISTANCE (FMA) Frequently Asked Questions (FAQ) What is the difference between this application (FMA) and the HMGP application submitted earlier this year? The two programs differ in two major ways: 1. Flood Insurance: The owner of each structure submitted in this application must have an active flood insurance policy that pre -dates October 1, 2018. 2. Homeowner Cost Share: It is lower for FMA projects: a. For RL properties, FEMA covers 90% of the project and the homeowner covers the remaining 10%. b. For SRL properties, FEMA covers 100%. c. For Non-RL/SRL, FEMA covers 75%. How do I know if my home is a Repetitive Loss (RL) or Severe Repetitive Loss (SRL) Property? If you are uncertain as to whether your property is deemed as a RL or SRL property, please contact George Shaw with the City of Tybee Island at 912-472-5031 for confirmation. Due to the sensitive nature of this private information, it will not be shared publicly or online. But what about Duplication of Benefits, can I still apply to this program even though my property was submitted under the HMGP application? YES! As the funding decision for the HMGP application has not yet been made, homeowners who are eligible for this program should apply. If homeowners who applied to both programs are approved under the HMGP program before the FMA funding decision is made, we will work with them on a case-by-case basis to determine the best way forward. How will mitigation affect my flood insurance rates? As risks change, insurance premiums may also change to reflect those risks. Please check with your insurance agent for details. If I elevate my home, do I have to bring everything else up to code? If the elevation project qualifies as a substantial improvement, the structure may have to be brought into compliance with all applicable codes and standards, not just those that apply to floodplain management. Check with the local building department for additional details. My house is currently on the market, but I am interested in participating. What if it sells? If a home is sold during application review and the proposed project is awarded, then the new property owner will be consulted for participation in the grant. All participation is voluntary. What documents am I required to submit and retain? It is preferable that you complete all forms in the Document Package to the best of your ability and retain copies of all documents. Some forms will require notarization. What if something unexpected happens during project implementation? Notify the City immediately of any potential changes in project performance or anticipated completion.