Emergency Management

2301 University Dr, Bldg 21 Bismarck ND 58504

(701) 222-6727

October 24, 2011 Information Meeting

Hazard Mitigation Grant Program (HMGP)

for Home Acquisitions

1. Sign-in

2. Welcome

3. Map of area being considered (Mary Senger)

4. Hazard Mitigation Grant Program process (Ray Morrell)

5. Review of forms required from each property owner (Ray Morrell)

6. Question and answer period

BRIARDALE 2NDSUBDIVISION

BRIARDALE 3RDSUBDIVISION

8718 SOUTHFORK JT 8721 SOUTHFORK JT

8801 SOUTHFORK JT8855 SOUTHFORK JT 8835 SOUTHFORK JT

7809SIBLEY DR

7700SIBLEY DR7724SIBLEY DR

7900SIBLEY DR7901SIBLEY DR8000SIBLEY DR

8000BRIARDALE LP8329BRIARDALE LP

8201SIBLEY DR 8100BRIARDALE LP 8103BRIARDALE LP

8300BRIARDALE LP

8111 SHADYVIEW PL8317SIBLEY DR8119 SHADYVIEW PL

8329SIBLEY DR

8520 SOUTHFORK JT

8417 SOUTHFORK JT

8601 SOUTHFORK JT8503 SOUTHFORK JT

8603SOUTHFORK JT

8836SOUTHFORK JT

8009BRIARDALE LP

8600SOUTHFORK JT

8720SOUTHFORK JT

8415SIBLEY DR

Property Considered For Grant ProgramSubdivision100 Year Floodplain500 Year Floodplain

Map produced by Burleigh County GIS. This map is for representation use only and does not represent a survey. No liability is assumed as to the accuracy of the data delineated hereon.

PROPERTIES CONSIDERED FOR THE FLOOD ACQUISITION GRANT PROGRAMBURLEIGH COUNTY, NORTH DAKOTA ±

10/18/2011

October 24, 2011 Information Meeting

Hazard Mitigation Grant Program (HMGP) for Home Acquisitions

Voluntary Participation Home acquisitions (buyouts) are strictly voluntary. No homeowners are ever forced to relinquish their property. Steps of Home Acquisition through the Hazard Mitigation Grant Program Homeowners do not apply to the Federal Emergency Management Agency (FEMA) for an acquisition grant. Home acquisitions are not part of the disaster application process and are not part of any individual assistance disaster program. 1. A grant application is prepared by local officials with input from the community and those

owners of flood prone homes. The local officials will have been informed on what constitutes a complete, eligible application for Hazard Mitigation Grant Program funds; and, in the case of home acquisitions, what requirements the local officials must adhere to if the application is funded and executed.

2. The State receives and reviews the grant application for completeness and eligibilities. The State will review all eligible applications and rank them for a level of priorities for funding. This ranking is based on set factors that are assessed on each potential project submission.

3. When projects have been vetted for application completeness and ensure all eligibilities have been met, the State will submit these project applications (in ranking order) to the FEMA Region VIII Mitigation Section in Denver.

4. FEMA will review the applications in accordance with Federal Law (Title 44 of the Code of Federal Regulations).

5. Once FEMA confirms the application meets all federal eligibilities, they inform the State. The State will assemble a HMGP award package notification for the local officials to confirm, sign, comply with and execute. Upon acceptance of this grant award (if deemed eligible and fundable) the local officials may begin the process for home acquisitions.

6. The local community (County) actually conducts the purchase and title transfer and will then own these structures and the land they sit on. Acquisition will only address the primary residential dwelling (home) and one detached garage. If the home does not have a detached garage, it may include one yard shed. If the home has an attached garaged, it is considered part of the home.

7. Upon the County conducting a real estate transfer (closing) on the property; the buildings are then removed or destroyed in accordance with applicable local, state, and federal regulations. The land is cleared, and a deed restriction is applied to the land restricting any permanent future construction for perpetuity.

Since home acquisitions are not simple matters and require a great deal of education and community input- it does not happen overnight. It may take months for the affected community to agree to acquisition proposals and submit a complete, eligible application for grant funds. It takes even longer for these applications to be confirmed as complete and eligible allowing for possible funding to be obligated. Once a homeowner accepts a buyout offer, though, the average closing takes about 45 days. Grant Application Timeframe Property owner deadline to participate in the grant application: November 28, 2011. County grant application due to ND Department of Emergency Services: January 27, 2012. ND Department of Emergency Services reviews application. Grant Award • 75% of grant award provided by FEMA • 17½% of grant award provided by State of ND • 7½% of remaining grant award is the homeowner’s responsibility for appraisal fees, legal

fees, publications, demolition costs, environmental surveys, hazardous materials inspection and abatement, etc.

Duplication of Benefits Because federal funds are used to acquire property, FEMA cannot duplicate the benefits paid by one program with benefits from another source. This means that FEMA will require the community to subtract from the purchase price, the amount of other assistance the individual property owner might receive for the same purpose. This assistance includes flood insurance and grants that are available to individuals. However, if the property owner has receipts or invoices accompanied by proof of purchase (cancelled checks/credit card invoices) showing that the money was spent for its intended purpose (for example, repairing the home to make it livable again), the community will not subtract that amount documented by receipts. The expenses being presented for the purposes of offsetting possible duplication of benefits will be reviewed and validated as eligible expenses.

Emergency Management

2301 University Dr, Bldg 21 Bismarck ND 58504

(701) 222-6727

Forms to be completed and signed by property owners: All forms are due by November 28th except as highlighted below Affidavit (must be notarized)

Declaration and Release

Eligibility and Policy Statement

Hazardous Materials Property Survey

Privacy Act Release

Statement of Voluntary Participation (Due November 4th) Additional information provided: Duplication of Benefits Fact Sheet: Information on how/why duplication of benefits is determined. Hazardous Materials Property Survey Instructions: Information on how to complete the Hazardous Materials Property Survey. Uniformed Rental Assistance (URA) Fact Sheet: Explains URA requirements if acquisition property is a rental unit and renters are displaced.

Page 1 of 4

DUPLICATION OF BENEFITS (DOB) FACT SHEET

What is “duplication of benefits”?

Various forms of assistance and programs (e.g., flood insurance, disaster repair grants, loans, etc.) help people whose properties have been damaged by natural disasters to rebuild and relocate. If your community is offering to purchase your home for its pre-disaster value with Federal grant funds, it must check for duplication of benefits. The total assistance you receive from all programs and insurance combined cannot exceed the fair market value (FMV) of your property before the disaster occurred. By law, Federal assistance cannot duplicate the benefits provided by other sources. That would be considered a duplication of benefits, or DOB. Consequently, if property owners have already received assistance to repair their properties from one program, the other program (including the property acquisition program) must ensure they don’t provide assistance to cover the same loss.

Who determines DOB?

The State and community will ensure that the acquisition offer doesn’t duplicate previous assistance. The community provides the State with a list of property owners who agree to voluntarily sell their properties to the community. The State then requests information about grants and insurance paid to the owners from FEMA, NFIP and SBA. The community and property owners cannot close on the property until the DOB determination is made.

How will NDDES and FEMA know if I have received other benefits?

Your community will ask you to provide a list of benefits you have received. NDDES and FEMA will double-check the information you provided with its own records. When you applied for assistance, you were asked to sign a Privacy Act disclosure form. By signing that form, you have given NDDES and FEMA permission to research and identify sources and amounts of federal assistance provided to you.

I want to sell my property, but I have received other benefits. How does DOB affect me?

First, you and the community will agree on a fair and reasonable price for your property. If it is determined that you have received disaster assistance that is DOB, the community will then subtract the total amount of DOB from that price. The community will pay you the difference. For example, if you and the community agree that $80,000 is a fair and reasonable price for your home and the community determines that you have received $5,000 that qualifies as DOB, the community will deduct that amount from the $80,000 and pay you $75,000. Please note that only disaster assistance used for home (housing or real property) repairs and/or rent for alternative accommodations that you cannot document with receipts will be subtracted from the sale price of your home.

Page 2 of 4

DUPLICATION OF BENEFITS (DOB) FACT SHEET (Continued)

Why subtract that $5,000?

To comply with federal law, NDDES and FEMA considers assistance identified as DOB as funds already contributed by the federal government towards the pre-disaster fair market value (FMV) of your property. NDDES and FEMA require the community to subtract funds that cannot be documented with receipts, from the final price paid to you at closing.

Please note, if you used the disaster assistance provided to you for home (housing or real property) repairs and/or rent for alternative accommodations and you have the receipts to document the use of the funds for those purposes, NDDES and FEMA will not consider the assistance DOB, and will not require the community to subtract that amount from the price of your property. Therefore, please keep all receipts from purchases and services that were paid for with disaster assistance grant funds.

What programs might duplicate HMGP benefits?

Assistance under the following programs might be considered DOB:

FEMA Disaster Housing Program

Disaster Housing (DH) Program home repair grants are awarded to property owners to repair the home to a habitable condition. DH rental assistance grants are awarded to property owners to rent accommodations in which the pre-disaster household can live. Both types of these grants are deducted from the purchase price only if you cannot provide receipts that document the costs for the repairs to your home and/or rent for alternative accommodations.

Individual and Family Grant (IFG) Program

Grants for housing (or real property) repairs may be awarded by the IFG Program. IFG grant funds designated for housing repairs only are deducted from the purchase price if you cannot provide receipts that document the costs for the repairs. IFG grant funds used for any other eligible purpose are not considered DOB and are not deducted from the purchase price.

Page 3 of 4

DUPLICATION OF BENEFITS (DOB) FACT SHEET (Continued)

Hazard Minimization Funds Disaster Housing and IFG-eligible property owners may receive a grant to implement measures that help prevent repeated damage. Hazard Minimization funds will be deducted from the purchase price only if you cannot provide receipts that document the costs for the measures.

Small Business Administration (SBA) loans

SBA loans must be either repaid or rolled over to the new property.

National Flood Insurance Program (NFIP)

NFIP Settlements for real property will be deducted. NFIP settlements for personal property will not be deducted. (Real property is immovable property such as land for a building. All other property is considered personal property.)

Private Insurance Private insurance claim payments for real property will be deducted. Personal property claim payments will not.

Page 4 of 4

DUPLICATION OF BENEFITS (DOB) FACT SHEET

POSSIBLE SCENARIOS

Mr. and Mrs. Mostovich own a single family home in the floodplain that was substantially damaged during a flood. They have decided to participate in their community’s property acquisition project and sell their home to the community. The pre-flood fair market value (FMV) of their home is estimated to be $50,000, which Mr. and Mrs. Mostovich agree is fair and reasonable. Since the disaster, they have received an NFIP real property settlement for $15,000, a Disaster Housing Program grant for $10,000, and an IFG Program grant of $5,000 designated for housing repairs (real property) only.

Scenario 1

Mr. and Mrs. Mostovich decide to make no repairs to their home and save the $30,000 they have received in assistance to put toward a new home. Consequently, FEMA considers the $30,000 as a down payment on their damaged home. The community can offer them no more than an additional $20,000 ($50,000 FMV minus $30,000 DOB = $20,000) for their home.

Scenario 2

Mr. and Mrs. Mostovich decide to make enough repairs to their home to enable them to live in it until the community buys it. Of the $30,000, they spent $10,000 to clean and disinfect the house, remove debris from the house and yard, and make minimum repairs to the foundation. They save all the receipts for the work and, therefore, can prove they used the assistance for its intended purpose. Consequently, the community can offer them an additional $30,000 ($50,000 FMV minus $30,000 = $20,000 plus $10,000 worth of repairs for which they have receipts = $30,000).

Scenario 3

The National Guard evacuated Mr. and Mrs. Mostovich and their neighbors from their neighborhood. Their car, which was left in their garage, was damaged beyond repair by the floodwaters. They decide to use $7,000 of the $30,000 to pay cash for another car. They make no repairs to their home. Since the flood damaged their car, they assume that buying a replacement car is an appropriate expense for which to use their assistance. They saved the bill of sale and expect the community to offer them $27,000 ($50,000 FMV minus $30,000 DOB plus $7,000 = $27,000). A car is not real property and should be covered by an automobile policy. Despite having a bill of sale, replacing a car is not an appropriate real property assistance expense. The community can offer them no more than an additional $20,000 ($50,000 FMV minus $30,000 DOB = $20,000).

Form II-10, Affidavit

Page 1 of 1

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 Burleigh County 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 State of North Dakota County of __________ The foregoing instrument was acknowledged before me this ___ day of __________________, 20_____, by ___________________________________. _____________________________________ (seal/stamp) Print, Type or Stamp Name of Notary My commission expires__________________

FEMA Form 009-0-3, AUG 2010 REPLACES ALL PREVIOUS FEMA Form 90-69B

DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY

DECLARATION AND RELEASEO.M.B. No. 1660-0002

Expires August 31, 2013

DECLARATON AND RELEASE In order to be eligible to receive FEMA Disaster Assistance, a member of the household must be a citizen, non-citizen national or qualified alien 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 of 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.

Print full name and age of minor child: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). I 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 Custom 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 I 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.

PRIVACY ACT STATEMENT AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5121 -5207 and Reorganization Plan No. 3 of 1978; 4 U.S.C. §§ 2904 and 2906; 4 C.F.R. § 206.2(a)(27); the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193) and Executive Order 13411. DHS asks for your SSN pursuant to the Debt Collection Improvement Act of 1996, 31 U.S.C. § 3325(d) and § 7701(c) (1). PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administering financial assistance under a Presidentially-declared disaster. Additionally, information may be reviewed internally within FEMA for quality control purposes. ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster Recovery Assistance Files System of Records (September 24, 2009, 74 FR 48763) and upon written request, by agreement, or as required by law. DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent the individual from receiving disaster assistance.

PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average .033 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 this form. You are not required to respond to this collection of information unless a valid OMB control number is displayed on 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, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0002) NOTE: Do not send your completed form to this address.

NAME (print) SIGNATURE DATE OF BIRTH

STATE ZIP CODE

FEMA APPLICATION NO. DISASTER NO.

CITY

INSPECTOR ID NO.

ADDRESS OF DAMAGED PROPERTY

DATE SIGNED

ND 58504

(leave blank) DR-1981-ND

Bismarck

(leave blank)

DISASTER NO. DR-_____-ND

ELIGIBILITY AND POLICY STATEMENT

In of 20 , the City/County of will apply to the North Dakota

Department of Emergency Services for funding under the Hazard Mitigation Program to acquire flood

damaged property from willing property owners living in the City/County of . The

purpose of the Hazard Mitigation Grant Program (HMGP) is to provide grant funding for projects/actions

that serve to reduce the likelihood of damages resulting from future disaster events.

recognizes that participation by property owners in this program is voluntary

and property owners may decide not to participate in the acquisition program any time prior to the

date of closing.

The statements below are designed to provide property owners with information regarding the

acquisition process that will be followed by the City/County of as part of the

Hazard Mitigation Program, and to provide the City/County of with

verification that each owner was presented with this information.

Each property owner who wishes to continue being considered for the Hazard Mitigation Program is

requested to read the following statements, complete any blank lines with appropriate information

pertaining to his/her property and to sign the signature line at the bottom of the next page.

1. I/We am/are the owner(s) of the

property identified at the following address:

2. I/We have been notified by the City/County of that it may wish to

purchase my/our property identified above under the Hazard Mitigation Grant Program, and

that if I/we agree to sell, it will be necessary for me/us to permanently move from the property.

3. I/We have been notified that the City/County of may reject a property

for acquisition due to ineligibility, fiscal constraints or other policy considerations.

4. I/We have been notified by the City/County of , that pre-flood fair

market value of the property will be offered (unless I/we purchased the property post-flood) as

determined by two appraisals prepared by appraisers certified by the State of North Dakota.

5. I/We have been informed by the City/County of that I/we/am/are not

required to sell the above property. The City/County of not use the

power of eminent domain to acquire the property in the event that I/we do not wish to sell the

above property. This means the acquisition program is voluntary.

6. I/We have been notified by the City/County of that if the above

property is sold voluntarily, I/we am/are not entitled to relocation benefits provided by the

DISASTER NO. DR-_____-ND

Uniform Relocation Assistance and Real Property Acquisition Policies Act, which is available to

persons forced to abandon their property involuntarily, and I/we will not claim any benefits.

7. I/We understand that duplication of Federal benefits through Federal financial disaster

assistance is prohibited, and that it is required to deduct from the purchase offer for my

property certain types of assistance which I/we have received as a result of flood damage to my

property. I/We also understand that my/our failure to fully disclose any benefits that I/we have

received may result in disqualification from this voluntary acquisition program. Therefore, I/we

authorize the City/County of to request and receive any Federal

Emergency Management Services Agency duplication of benefits information.

8. The City/County of stipulates and agrees that the above property

is not part of an intended, planned or designated project area for which the land is to be

acquired by a certain date, and/or where there is an intention to use the property for any public

or private future use inconsistent with the open space deed restrictions and FEMA acquisition

requirements.

Please sign below if you have read and understand the statements included in this

ELIGIBILITY AND POLICY STATEMENT.

Signature:

Property Owner Date

Property Owner Date

Signature:

City Official/Title Date

INSTRUCTIONS FOR COMPLETING THE HAZARDOUS MATERIALS PROPERTY SURVEY

INDIVIDUAL PROPERTY SURVEY FORM

Why are we asking for this information about your property?

Normal property transactions involve an inspection of the property by the buyer before the purchase occurs. One area of concern to buyers is the potential for hazardous materials liability. Sellers are usually required to provide assurance or evidence to the buyer that hazardous materials do not contaminate the property. This survey provides that assurance to the Government as well as provides some legal protection to the seller. If the survey indicates possible contamination, FEMA or your state or local government can provide guidance to the seller for addressing any hazardous-materials-related concerns.

Points to consider when answering the survey questions:

Please type or print.

All property owners should be identified and participate in completing the survey, and sign the survey.

Anyone who assists the property owner in completing the survey should be identified as a preparer.

Answer the survey to the best of your knowledge; fully investigate each answer.

Consult with previous owner(s) and/or neighbors whenever possible regarding past use of your property, underground storage tanks, presence of hazardous materials, and environmental violations or studies.

Walk your property looking for anything unusual or previously unnoticed.

Attach a sheet of paper to complete your answers, if necessary. Note any information of interest not specifically requested in the survey that might indicate contamination of the property by hazardous materials.

On a residential property, commercial, and light industrial uses might include activities such as commercial auto repair in the home garage, paint stripping, hairdressing, woodworking, etc. Because not all in-home commercial activities involve hazardous materials, make sure to indicate the specific type of in-home commercial business activity under question #1.

Many historic railroad yards, railroad rights-of-way, parking lots, and roadway rights-of-way have been abandoned and reverted back to adjoining landowners. If there was any previous transportation facility, note the specific use in question #4. (For example, the property might have been used to store heavy equipment or vehicles, or as a repair shop.)

Retain a copy of the survey for your own records.

Address your questions to your community’s point of contact.

Page 1 of 3

HAZARDOUS MATERIALS PROPERTY SURVEY INDIVIDUAL PROPERTY SURVEY FORM

Owner’s Name(s):

Property Address:

Jurisdiction (property):

Owner’s Address:

Owner’s Telephone Numbers

Day: Evening: Other:

I/We, as owner(s) of the above referenced property, represent and certify that I/we have, to the best of my/our ability, used due diligence to determine that the description of the property described herein is accurate with respect to the presence or absence of contamination from toxic or hazardous substances. The term “property” refers to the physical piece of legally recorded land that is to be acquired.

Please thoroughly answer the following questions. Use additional sheets of paper as necessary.

1. Is or was the property used for governmental, commercial, light industrial or industrial activities? If yes, identify specific type and nature of activities. Yes No

2. Are any aboveground storage tanks (ASTs), underground storage tanks (UST), or leaking underground storage tanks present on property? If yes, identify the type, capacity, and condition of each tank. Yes No

Page 2 of 3

3. At any time, has any generation, treatment, storage, disposal, release, or spill of petroleum products, solid or hazardous substances and/or waste (to include pesticides, herbicides, or rodenticides) occurred on what is now your property, other than normal quantities of household substances? If yes, identify each type of activity, substance, and quantity. Yes No

4. At any time, has a transportation facility (to include parking lots, railroad yards, or railroad or roadway right-of-way) been present on what is now your property? If yes, identify type of facility or activity. Yes No

5. Have you noticed any unusual odors or discolorations in your drinking water? Yes No

6. At any time, have any environmental investigations been conducted by federal, state, or local agencies or private firms; or any environmental or Occupational Safety and Health Administration (OSHA) citations or notices of violation been issued regarding what is now your property? If yes, identify the type of investigation or violation, and the preparer or origin of the investigation or violation. Yes No

Page 3 of 3

The property owner(s) acknowledge that this certification regarding hazardous substances and/or waste is a material representation of fact on which the Hazard Mitigation Grant Program sub-grantee and other government entities rely on to execute the purchase of the property. The property owner(s) certify that the information contained herein is a full disclosure of all available information to the best of owner’s(s’) knowledge, and that owner(s) has exercised due diligence in obtaining all relevant information.

Preparer

Signature Date

Name (Typed or Printed) Title

Property Owner(s)

Signature Date

Name (Typed or Printed)

Signature Date

Name (Typed or Printed)

Acquisition Privacy Act Release DISASTER NO. DR-_______-ND March 2011

Page 1 of 2

PRIVACY ACT RELEASE

I, the undersigned, grant permission for the Federal Emergency Management Agency (FEMA) to release

information from my Disaster Recovery Assistance File to ____________________________________

(City/County/State) for purposes of a possible sale of property to

(City/County/State), under its Voluntary Acquisition Program.

Print Name:_______________________________ Spouse: ___________________________________ First/Middle/Last First/Middle/Last Print Address: _____________________________ __________________________________ Street Address Street Address _____________________________ __________________________________ City/State/Zip Code City/State/Zip Code Date of Birth:______________________________ Date of Birth:_____________________________ Social Security #:___________________________ Social Security #:__________________________ Home Telephone:__________________________ Home Telephone:_________________________ Other Telephone:__________________________ Other Telephone:_________________________ (Circle One): Work, Cell, Pager, Fax, Friend/Relative, Other (Circle One): Work, Cell, Pager, Fax, Friend/Relative, Other

Other Owner:

Print Name:_______________________________ Spouse: ___________________________________ First/Middle/Last First/Middle/Last Print Address: _____________________________ __________________________________ Street Address Street Address _____________________________ __________________________________ City/State/Zip Code City/State/Zip Code Date of Birth:______________________________ Date of Birth:_____________________________ Social Security #:___________________________ Social Security #:__________________________ Home Telephone:__________________________ Home Telephone:_________________________ Other Telephone:__________________________ Other Telephone:_________________________ (Circle One): Work, Cell, Pager, Fax, Friend/Relative, Other (Circle One): Work, Cell, Pager, Fax, Friend/Relative, Other

Acquisition Privacy Act Release DISASTER NO. DR-_______-ND March 2011

Page 2 of 2

1. Did you have flood insurance prior to the flood?

(Circle One): Yes No

2. Did you receive flood Insurance payments for flood?

(Circle One): Yes No

3. Did you receive other insurance payments for flood related damage to your home?

(Circle One): Yes No

If yes, please complete the following information:

Name of Insurance Company:

Policy Number:

Agent Name/Phone Number:

If you applied to FEMA for benefits, enter your nine character Control Number:

Address of Property:

Street Address

City/State/Zip Code

_____________________________________________________________________________________

Signature Date

_____________________________________________________________________________________

Signature Date

_____________________________________________________________________________________

Signature Date

_____________________________________________________________________________________

Signature Date

STATEMENT OF VOLUNTARY PARTICIPATION

This agreement is made and entered into this day of , 20 , by and

between , , hereinafter referred to as “Sub-grantee,” by its authorized agent,

, and , hereinafter referred to

as “Seller.” The parties agree as follows:

1. Seller affirms that he/she/they is/are the owner(s) of property located at

, hereinafter referred to as “property.”

2. Sub-grantee has notified Seller that the Sub-Grantee may wish to purchase property, and, if

Seller agrees to sell, Seller must permanently relocate from property.

3. Sub-grantee has notified seller that it believes the fair market value (FMV) of property, as of

, is $ as determined by appropriate valuation

procedures publicized and implemented by Sub-grantee.

4. Sub-grantee has notified Seller that Seller is not required to sell property and Sub-grantee will

not use its power of eminent domain for the purpose of this acquisition project to acquire

property if Seller chooses not to sell it.

5. Sub-grantee has notified Seller that if Seller agrees to sell property to Sub-grantee, such a

transaction is voluntary. Consequently, Seller is not entitled to relocation benefits provided by

the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, which are

available to property owners who must sell their properties involuntarily.

6. Sub-grantee affirms that it has provided the notifications and explained the information

described in the preceding paragraphs, and property identified above is not a part of an

intended, planned or designated project area where all or substantially all of the property within

the area is to be acquired within specific time limits.

7. This agreement shall expire on , unless Seller has voluntarily sold

property to Sub-grantee by that date.

Property Owner Signature Date

Property Owner Signature Date

Sub-grantee’s Authorized Agent Signature Date