Free 50356.pdf - Indiana

State Form 50356 (R/7-02) Page 1 of 2

Request for Floodplain Analysis and Regulatory Assessment
(No Fee Is Required For This Assessment)

This is Not an Application for a Permit Individual citizens should use this form for floodplain information requests such as: · Flood Insurance determinations required by a mortgage lender · Permit requirements for construction of a proposed structure or obstruction in a floodway (examples: fence, building, fill, excavation, pond, bridge, culvert, bank protection) · Requirements for construction of a house or placement of a manufactured home 1. Type of request (Check All That Apply): Flood Insurance Determination 100-Year Flood Elevation Determination (Base Flood Elevation Determination) Information for a LOMA (Letter of Map Amendment)/LOMR (Letter of Map Revision) Floodway Determination Residential Structure Existing Replacement Proposed Non-Residential Structure Existing Proposed, describe Addition to a Building Residential Non-Residential Bridge or Culvert New Replacement Rehabilitation Other, describe Floodplain assessments require accurate site location information that you must provide with your request. Failure to submit complete information may result in a lengthy delay. 2. Site Location: Section Site Address County , Nearest Stream / Water Body , Township N / S, Range E / W; Grant No. , City

3. Site Map / Description: The following location or map information must be submitted in order to process your request. Additional information may be requested. · For all flood insurance determinations, use map type 3a (where applicable) and 3b. See examples on page 2. · For sites in urban areas use map type 3a, 3b, or 3d. See examples on page 2. · For sites in rural areas use map type 3b, 3c, or 3d. See examples on page 2. 4. Contact Person: Name Address Telephone ( Signature ) , Fax ( ) , City , Email , Date Agency Use Only FARA No. CSC Initial , State , Zip

Send completed form and supporting information to:
Indiana Department of Natural Resources Division of Water Attention: Technical Services Section 402 West Washington St., Room W264 Indianapolis, IN 46204-2641

Processing may require 4 to 6 weeks. Contact a Division of Water Technical Services Representative if you need help completing this form. Phone: (317) 232-4160 Toll Free: (877) 928-3755 Fax: (317) 233-4579 Email: [email protected]
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State Form 50356 (R/7-02) Page 2 of 2

Request for Floodplain Analysis and Regulatory Assessment Site Map/Description Instructions and General Guidelines
Before the Division of Water can evaluate your request, an accurate site location map must be submitted. Examples of acceptable maps are shown below. All maps must include a scale and a north arrow.
3a) Subdivision Plat with Lot # marked This information may be obtained from the County Recorder's Office 3b) Surveyor Location Report (mortgage survey) and Legal Description This information may be filed with documents received at the mortgage closing

3c) A copy of the Property Survey This information may be obtained from the County Recorder's Office

3d) A copy of the USGS topographical survey map with site location marked This information may be obtained from DNR Map Sales Office Phone: (317) 232-4180