Old form with changes

U.S. DEPARTMENT OF HOMELAND SECURITY - Federal Emergency Management Agency PROPERTY INFORMATION FORM

O.M.B. NO. 1660-0015 Expires December 31, 20102013

PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form 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, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid 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, U.S. 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 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 maywill result in processing delays. Please check the item below that describes your request:
LOMA	A letter from DHS-FEMA stating that an existing structure or parcel of land that has not been elevated by fill (natural grade) would not be inundated by the base flood.
CLOMA	A letter from DHS-FEMA stating that a proposed structure that is not to be elevated by fill (natural grade) would not be inundated by the base flood if built as proposed.
LOMR-F	A letter from DHS-FEMA stating that an existing structure or parcel of land that has been elevated by fill would not be inundated by the base flood.
CLOMR-F	A letter from DHS-FEMA stating that a parcel of land or proposed structure that will be elevated by fill would not be inundated by the base flood if fill is placed on the parcel as proposed or the structure is built as proposed.
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. Has fill been placed on your property to raise ground that was previously below the BFE? Yes No If yes, when was fill placed?      /     month/year Will fill be placed on your property to raise 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).
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):       Legal description of Property (Lot, Block, Subdivision)(complete or abbreviated description as it appears infrom the Deed is not necessary):       Are you requesting that the SFHA designationa flood zone determination be removed fromcompleted for (check one): the entire legally recorded property?Structures on the property? What are the dates of construction? _______________ (MM/YYYY) aA 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.) structures on the property? What are the dates of construction?      The entire legally recorded property? Is this request for a (check one): singleSingle structure singleSingle lot multipleMultiple structures (How many structures are involved in your request? List the number:      _______) multipleMultiple lots (How many lots are involved in your request? List the number:      _______)
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.

In addition to this form (MT-1 Form 1), ALL requests must include the following: Copy of the effective FIRM panel and/or Flood Boundary and Floodway Map (FBFM) (if applicable) on which the 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 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 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
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):       Please Print or Type Mailing Address: (required):             E-Mail Address:       (optional)): By checking here you may receive correspondence electronically at the email address provided):       Date (required)	Company: (if applicable):       Daytime Telephone No.:. (required):       Fax No.:. (optional):       ___________________________________________________________ Signature of Applicant (required)
If you have any questions concerning DHS-FEMA policy, or the NFIP in general, please contact the FEMA Map Assistance Center toll free at 1-877-FEMA MAP (1-877-336-2627), or visit the Flood Hazard Mapping website at http://www.fema.gov/fhm/.

DHS - FEMA Form 81-87, DEC 0710 Property Information Form MT-1 Form 1 Page 1 of 2