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<br />. <br /> <br />APPENDIX .3 <br /> <br />REPETITIVE LOSS INFORMATION REQUEST FORM <br /> <br />Please provide any repetitive loss information relating to the <br /> <br />City/County Name <br />I hereby recognize that the flood insurance information that will be provided contains individual <br /> <br />flood insurance policy information that is protected under the Privacy Act Notice. It is understood <br /> <br />that <br /> <br />and its employees may only use this information to assist <br /> <br />City/County Name <br />in administering or implementing floodplain management and other hazard mitigation programs. <br /> <br />Signature of Authorized Certifying Official <br /> <br />Date <br /> <br />. Print Name and Title of Authorized Certifying Offici!!l <br /> <br />. <br /> <br />Signature of Primary Person Utilizing the Information <br /> <br />Date <br /> <br />Print Name and Title of Primary Person Utilizing the Information <br />