Fill and Sign the Flood Zone Statement and Authorization West Virginia Form

Flood Zone Statement and Authorization Property Address: ____________________________________________________________ Statement by Sellers (Check one): _______ To the best of my/our knowledge the property at the address described above is not located in an area that has been identified as being flood prone as defined by the National Flood Insurance Act of 1968. _______ To the best of my/our knowledge the property at the address described above is located in an area that has been identified as being flood prone as defined by the National Flood Insurance Act of 1968. _______ The property at the address described above flood zone status is reflected in survey or Flood Certification form by ___________________________, a copy of which is attached. Statement by Buyers: I/We have been informed of the flood zone status of the property located at the address above. If after the date of this statement the Federal Insurance Administration of the Department of Housing and Urban Development together will the Federal Emergency Management Agency so determine that the above referenced property is located in an area that has been identified as being flood prone as defined by the National Flood Insurance Act of 1968, I/WE do hereby agree to obtain the necessary required flood hazard insurance and do hereby agree to have escrowed in our monthly payment 1/12th of the annual renewal premium for said flood hazard insurance. This paragraph applies so long as a loan is owed by Buyer(s) to any person. ___________________________________________________ _______________________________________________ Seller Date Buyer Date ___________________________________________________ _______________________________________________ Address Address ____________________________________________________ _______________________________________________ City State Zip City State Zip ___________________________________________________ _______________________________________________ Seller Date Buyer Date ___________________________________________________ _______________________________________________ Address Address ____________________________________________________ _______________________________________________ City State Zip City State Zip