Form 81-87B Community Acknowledgement Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
COMMUNITY ACKNOWLEDGEMENT OF FILL

O.M.B. No. 1660-0015
Expires August 31, 2007

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form 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, reviewing, and submitting the form.
You are not required to respond to this collection of information unless a vaild OMB control number appears in the upper right corner of 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, 500 C Street, SW, Washington, DC, 20472,
Paperwork Reduction Project (1660-0015). Submission of the form is required to obtain or retain benefits under the National Flood Insurance
Program. Please do not send your completed survey to the above address.
This form must be completed for request involving the existing or proposed placement of fill (complete Section A) OR to provide
acknowledgement 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 space provided below. Incomplete
submissions may result in processing delays.
Community Number:

Property Name or Address:

A. REQUEST 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. 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 44 CFR 65.2(c), and that we have available upon request by DHS-FEMA, all analysis and
documentation used to make this determination. For LOMR-F or Conditional LOMR-F that have the potential to impact an endangered
species, doucmentation wil be submitted to show that we have complied wioth Sections 9 and 10 of the Endangered Soecies Act (ESA).
Section 9 of the ESA prohibits anyone form "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 Fisheries Services under Section 10 of the ESA. For actions authorized,
funded, or being carried out by the Federal or State agencies, documentation from the agency showing its compliance with Secton 7(a)(2) of
the ESA will be submitted.
Community Comments:

Community Official's Name and Title (Please Print or Type)

Community Name

Telephone Number

Community 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 inadvertenly 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 Official's Name and Title: (Please Print or Type)

Community Name

FEMA Form 81-87B, FEB 06

Telephone Number

Community Official's Signature (Required)

Community Acknowledgment Form

Date

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