Form FEMA Form 086-0-26 FEMA Form 086-0-26 Community Acknowledgment

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

O.M.B. No. 1660-0015
Expires February 28, 2014

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, 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.
PRIVACY ACT STATEMENT
AUTHORITY: The National Flood Insurance Act of 1968, Public Law 90-448, as amended by the Flood Disaster Protection Act of 1973, Public Law
93-234.
PRINCIPAL PURPOSE(S): This information is being collected for the purpose of determining an applicant's eligibility to request changes to National Flood
Insurance Program (NFIP) Flood Insurance Rate Maps (FIRM).
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C § 552a(b) of the Privacy Act of 1974, as amended.
This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA/NFIP/LOMA-1 National Flood Insurance
Program (NFIP); Letter of Map Amendment (LOMA) February 15, 2006, 71 FR 7990.
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent FEMA
from processing a determination regarding a requested change to a (NFIP) Flood Insurance Rate Maps (FIRM).
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 that is 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 community number and the subject
property address must appear in the space provided below.
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 FEMA, all analysis and documentation used to make this determination. For LOMR-F requests, we
understand that this request is being forwarded to FEMA for a possible map revision
Community Comments:

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

Telephone Number

Community Name

Date

Community Official's Signature (Required)

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 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 Name

Community Official's Signature (Required)

Community Official's Name and Title: (Please Print or Type)
FEMA Form 086-0-26B, (2/2011)

Community Acknowledgment Form

Telephone Number
Date
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