FEMA Form MT1 – 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.

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-FEM!’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.

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

Property Information Form

MT-1 Form 1 Page 2 of 2

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 1.25 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 must be completed for requests and must be completed and signed by a registered professional engineer or licensed land surveyor. A DHS - FEMA National

Flood Insurance Program (NFIP) Elevation Certificate may be submitted in lieu of this form for single structure requests.

For requests to remove a structure on natural grade OR on engineered fill from the Special Flood Hazard Area (SFHA), submit the lowest adjacent grade (the lowest ground touching the structure), including an attached deck or garage. For requests to remove an entire parcel of land from the SFHA, provide the lowest lot elevation; or, if the request involves an area described by metes and bounds, provide the lowest elevation within the metes and bounds description. All measurements are to be rounded to nearest tenth of a foot. In order to process your request, all information on this form must be completed in its entirety. Incomplete submissions will

result in processing delays.

1. NFIP Community Number:

Property Name or Address:

3.For the existing or proposed structures listed below, what are the types of construction? (check all that apply)

crawl space

slab on grade

basement/enclosure

other (explain)

5. What is the elevation datum? NGVD 29

NAVD 88

Other (explain)

If any of the elevations listed below were computed using a datum different than the datum used for the effective Flood Insurance Rate Map (FIRM) (e.g., NGVD 29 or NAVD 88), what was the conversion factor?

Local Elevation +/- ft. = FIRM Datum

6.Please provide the Latitude and Longitude of the most upstream edge of the structure (in decimal degrees to the nearest fifth decimal place):

Indicate Datum:

WGS84

NAD83

NAD27 Lat.

.

Long.

.

Please provide the Latitude and Longitude of the most upstream edge of the property (in decimal degrees to the nearest fifth decimal place):

Indicate Datum:

WGS84

NAD83

NAD27 Lat.

.

Long.

.

This certification is to be signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify elevation information. 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.

ertifier’s Name.	License No.:	Expiration Date:
Company Name:	Telephone No.:

* For requests involving a portion of property, include the lowest ground elevation within

the metes and bounds description.Seal (optional) Please note: If the Lowest Adjacent Grade to Structure is the only elevation provided, a determination

will be issued for the structure only.

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

Elevation Form

MT-1 Form 2 Page 1 of 2

Continued from Page 1.

This certification is to be signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify elevation information. 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.

* For requests involving a portion of property, include the lowest ground elevation within

the metes and bounds description.Seal (optional) Please note: If the Lowest Adjacent Grade to Structure is the only elevation provided, a

determination will be issued for the structure only.

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

Elevation Form

MT-1 Form 2 Page 2 of 2

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 1.38 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 must be completed for requests involving the existing or proposed placement of fill (complete Section A) OR to provide acknowledgment of this request to remove a property from the SFHA which was previously located within the regulatory floodway (complete Section B).

This form must be completed and signed by the official responsible for floodplain management in the community. The six digit NFIP community number and the subject property address must appear in the spaces provided below. Incomplete submissions will result in processing delays. Please refer to the MT-1 instructions for additional information about this form.

Community Number: ____________________

Property Name or Address: ____________________________________________

A. REQUESTS INVOLVING THE PLACEMENT OF FILL

As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this Letter of Map Revision Based on Fill (LOMR-F) or Conditional LOMR-F request. Based upon the community's review, we find the completed or proposed project meets or is designed to meet all of the community floodplain management requirements, including the requirement that no fill be placed in the regulatory floodway, and that all necessary Federal, State, and local permits have been, or in the case of a Conditional LOMR-F, will be obtained. For Conditional LOMR-F requests, the applicant has or will document Endangered Species Act (ESA) compliance to FEMA prior to issuance of the

Conditional LOMR-F determination. For LOMR-F requests, I acknowledge that compliance with Sections 9 and 10 of the ESA has been achieved independently of FEM!’s process/ Section 9 of the ES! prohibits anyone from “taking” or harming an endangered species/ If an action might harm

an endangered species, a permit is required from U.S. Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA. For actions authorized, funded, or being carried out by Federal or State agencies, documentation from the agency showing its compliance with Section 7(a)(2) of the ESA will be submitted. In addition, we have determined that the land and any existing or proposed structures to be removed from the SFHA are or will be reasonably safe from flooding as defined in 44CFR 65.2(c), and that we have available upon request by DHS-FEMA, all analyses and documentation used to make this determination. For LOMR-F requests, we understand that this request is being forwarded to DHS- FEMA for a possible map revision.

Community Comments:

ommunity Official’s Name and Title. (Please Print or Type)		Telephone No.:
Community Name:	ommunity Official’s Signature. (required)	Date:

B. PROPERTY LOCATED WITHIN THE REGULATORY FLOODWAY

As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this request for a LOMA. We understand that this request is being forwarded to DHS-FEMA to determine if this property has been inadvertently included in the regulatory floodway. We acknowledge that no fill on this property has been or will be placed within the designated regulatory floodway. We find that the completed or proposed project meets or is designed to meet all of the community floodplain management requirements.

Community Comments:

ommunity Official’s Name and Title. (Please Print or Type)		Telephone No.:
Community Name:	ommunity Official’s Signature (required).	Date:

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

Community Acknowledgment Form

MT-1 Form 3 Page 1 of 1

FEDERAL EMERGENCY MANAGEMENT AGENCY

PAYMENT INFORMATION FORM

Community Name:

Project Identifier:

THIS FORM MUST BE MAILED, ALONG WITH THE APPROPRIATE FEE, TO THE ADDRESS BELOW OR FAXED TO THE FAX NUMBER BELOW.

Please make check or money order payable to the National Flood Insurance Program.

Type of Request:	LOMC Clearinghouse
MT-1 application	847 South Pickett Street
MT-2 application	Alexandria, VA 22304-4605
	Attn.: LOMC Manager

				FEMA Project Library
	EDR application			847 South Pickett Street
				Alexandria, VA 22304-4605
				FAX (703) 212-4090
Request No. (if known):	_______________		Check No.:	_______________		Amount:

*Note: Check only for EDR and/or Alluvial Fan requests (as appropriate).

**Note: Check only if submitting a corrected fee for an ongoing request.

COMPLETE THIS SECTION ONLY IF PAYING BY CREDIT CARD

CARD NUMBER

EXP. DATE

1 2 3 4		5 6 7 8	9 10 11 12	13 14 15 16	Month	Year
		_________________________________________________________________
Date				Signature

NAME (AS IT APPEARS ON CARD):

(please print or type)

ADDRESS: (for your credit card receipt-please print or type)

DAYTIME PHONE:

FEMA Form 81-107

Payment Information Form