Dhs Fema Form 086 0 26 – Fill Out and Use This PDF

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 1.63 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing and submitting the form. This collection is required to obtain 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. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0015). NOTE: Do not send your completed form to this address.

This form may be completed by the property owner, property owner’s agent, licensed land surveyor, or registered professional engineer to support a request for a Letter of Map Amendment (LOMA), Conditional Letter of Map Amendment (CLOMA), Letter of Map Revision Based on Fill (LOMR-F), or Conditional Letter of Map Revision Based on Fill (CLOMR-F) for existing or proposed, single or multiple lots/structures. In order to process your request, all information on this form must be completed in its entirety, unless stated as optional. Incomplete submissions will result in processing delays. Please check the item below that describes your request:

Fill is defined as material from any source (including the subject property) placed that raises the ground to or above the Base Flood Elevation (BFE). The common construction practice of removing unsuitable existing material (topsoil) and backfilling with select structural material is not considered the placement of fill if the practice does not alter the existing (natural grade) elevation, which is at or above the BFE. Fill that is placed before the date of the first National Flood Insurance

Program (NFIP) map showing the area in a Special Flood Hazard Area (SFHA) is considered natural grade.

ground that is below the BFE?		Yes*		No	If yes, when will fill be placed?	/
						month/year

*If yes, Endangered Species Act (ESA) compliance must be documented to FEMA prior to issuance of the CLOMR-F determination (please refer page 4 to the MT-1 instructions).

1.Street Address of the Property (if request is for multiple structures or units, please attach additional sheet referencing each address and enter street names below):

2.Legal description of Property (Lot, Block, Subdivision or abbreviated description from the Deed):

3.Are you requesting that a flood zone determination be completed for (check one):

Structures on the property? What are the dates of construction? _______________ (MM/YYYY)

A portion of land within the bounds of the property? (A certified metes and bounds description and map of the area to be removed, certified by a licensed land surveyor or registered professional engineer, are required. For the preferred format of metes and bounds descriptions, please refer to the MT-1 Form 1 Instructions.)

The entire legally recorded property?

4.Is this request for a (check one):

Single structure

Single lot

Multiple structures (How many structures are involved in your request? List the number: _______)

Multiple lots (How many lots are involved in your request? List the number: _______)

DHS - FEMA Form 086-0-26, FEB 11

Property Information Form

MT-1 Form 1 Page 1 of 2

In addition to this form (MT-1 Form 1), please complete the checklist below. ALL requests must include one copy of the following:

Copy of the effective FIRM panel on which the structure and/or property location has been accurately plotted (property inadvertently located in the NFIP regulatory floodway will require Section B of MT-1 Form 3)

Copy of the Subdivision Plat Map for the property (with recordation data and stamp of the Recorder’s Office)

OR

Copy of the Property Deed (with recordation data and stamp of the Recorder’s Office), accompanied by a tax assessor’s map or other certified map showing the surveyed location of the property relative to local streets and watercourses. The map should include at least one street intersection that is shown on the FIRM panel.

Form 2 – Elevation Form. If the request is to remove the structure, and an Elevation Certificate has already been completed for this property, it may be submitted in lieu of Form 2. If the request is to remove the entire legally recorded property, or a portion thereof, the lowest lot elevation must be provided on Form 2.

Please include a map scale and North arrow on all maps submitted.

For LOMR-Fs and CLOMR-Fs, the following must be submitted in addition to the items listed above:

Form 3 – Community Acknowledgment Form

For CLOMR-Fs, the following must be submitted in addition to the items listed above:

Documented ESA compliance, which may include a copy of an Incidental Take Permit, an Incidental Take Statement, a “not likely to adversely affect” determination from the National Marine Fisheries Service (NMFS) or the U.S. Fish and Wildlife Service (USFWS), or an official letter from NMFS or USFWS concurring that the project has “No Effect” on proposed or listed species or designated critical habitat. Please refer to the MT-1 instructions for additional information.

Please do not submit original documents. Please retain a copy of all submitted documents for your records.

DHS-FEMA encourages the submission of all required data in a digital format (e.g. scanned documents and images on Compact Disc [CD]). Digital submissions help to further DHS-FEMA’s Digital Vision and also may facilitate the processing of your request.

Incomplete submissions will result in processing delays. For additional information regarding this form, including where to obtain the supporting documents listed above, please refer to the MT-1 Form Instructions located at http://www.fema.gov/plan/prevent/fhm/dl_mt-1.shtm.

Processing Fee (see instructions for appropriate mailing address; or visit http://www.fema.gov/fhm/frm_fees.shtm for the most current fee schedule)

Revised fee schedules are published periodically, but no more than once annually, as noted in the Federal Register. Please note: single/multiple lot(s)/structure(s) LOMAs are fee exempt. The current review and processing fees are listed below:

Check the fee that applies to your request:

$325 (single lot/structure LOMR-F following a CLOMR-F)

$425 (single lot/structure LOMR-F)

$500 (single lot/structure CLOMA or CLOMR-F)

$700 (multiple lot/structure LOMR-F following a CLOMR-F, or multiple lot/structure CLOMA)

$800 (multiple lot/structure LOMR-F or CLOMR-F)

Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to:

National Flood Insurance Program.

All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code, Section 1001.

Applicant’s Name (required):	Company (if applicable):
Mailing Address (required):	Daytime Telephone No. (required):
	Fax No. (optional):
E-Mail Address (optional):	By checking here you may receive correspondence

electronically at the email address provided):
	___________________________________________________________
Date (required)	Signature of Applicant (required)

DHS - FEMA Form 086-0-26, FEB 11

Property Information Form

MT-1 Form 1 Page 2 of 2