Form FEMA Form 086-0-22 FEMA Form 086-0-22 Application Form For Single Residential Lot or Structure

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

APPLICATION FORM FOR SINGLE RESIDENTIAL LOT OR STRUCTURES AMENDMENTS TO
NATIONAL FLOOD INSURANCE PROGRAM MAPS

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

PAPERWORK REDUCTION NOTICE
Public reporting burden for this form is estimated to average 2.4 hours per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed and completing and submitting the form. This collection of information is
required to obtain or retain benefits. You are not required to respond to this collection of information unless it displays a valid OMB control number. You may
send comments regarding the burden estimate or any other aspect of the collection, including suggestions for reducing the burden to: Information Collections
Management, Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork
Reduction Project (OMB Control Number 1660-0037). Submission of the form is required to obtain or retain benefits under the the National Flood Insurance
Program.
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 should be used to request that the Department of Homeland Security's Federal Emergency Management Agency (FEMA) remove a single
structure or legally recorded parcel of land or portions thereof, described by metes and bounds, certified by a registered professional engineer or licensed
land surveyor, from a designated Special Flood Hazard Area (SFHA), an area that would be inundated by the flood having a 1%-chance of being equaled or
exceeding in any given year (base flood), via Letter of Map Amendment (LOMA). It shall not be used for request submitted by developers, for requests
involving multiple structures or lots, for property in alluvial fan areas or coastal high hazards areas (V zones), or request involving the placement of fill.
(NOTE: Use MT-1 forms for such request). Fill is defined as material from any source (including the subject property) placed that raises the grade to or
above the Base Flood Elevation (BFE). The common construction practiced 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 BFE. Also, fill
that is placed before the date of the first National Flood Insurance Program (NFIP) map showing the area in an SFHA is considered natural grade.
A letter from DHS-FEMA stating that an existing structure or parcel of land that has not been elevated
by fill would not be inundated by the base flood.

LOMA:

A - This section may be completed by the property owner or by the property owner's agent. In order to process your request, all information on this form must
be completed in its entirety, unless stated as optional. Incomplete submissions may result in processing delays.
1. Has fill been placed on your property to raise ground that was previously below the BFE?
NO

YES

If yes, STOP!! - You must complete the MT-1 application forms, visit
http://www.fema.gov/plan/prevent/fhm/dl_mt-1.shtm
or call the FEMA Map Information exchange toll free: (877-FEMA MAP) (877-336-2627)

2. Legal description of Property (Lot, Block, Subdivision; complete description as it appears in the Deed is not necessary) and street address of the Property
(required):

3. Are you requesting that a flood zone determination be completed for (check one):
A structure on your property? What is the date of construction?

(MM/YYYY)

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

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):

E-mail address (optional) (
By checking here you may receive
correspondence electronically at the e-mail address provided):

Mailing Address (Include Company name if applicable):

Daytime Telephone No. (required):
Fax No. (optional):

Signature of Applicant (required)

Date

End of Section A
FEMA Form 086-0-22, (2/2011)

MT-EZ Form Previously FF 81-92

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B - This section must be completed by a registered professional engineer or licensed land surveyor. Incomplete submissions will result in processing delays.
NOTE: If the request is to have a flood zone determination completed for the structure, and an Elevation Certificate has been completed
for this property, it may be submitted in lieu of Section B. If the request is to have a flood zone determination completed for the entire
legally recorded property, or a portion thereof, the lowest elevation on the lot or described portion must be provided. in Section B.
Applicable Regulations
The regulations pertaining to LOMAs are presented in the National Flood Insurance Program (NFIP) regulations under Title 44, Chapter I, Parts 70 and 72,
Code of Federal Regulations. The purpose of Part 70 is to provide an administrative procedure whereby DHS/FEMA will review information submitted by an
owner or lessee of property who believes that his or her property has been inadvertently included in a designated SFHA. The necessity of Part 70 is due in
part to the technical difficulty of accurately delineating the SFHA boundary on an NFIP map. Part 70 procedures shall not apply if the topography has been
altered to raise the original ground to or above the BFE since the effective date of the first NFIP map [e.g., a Flood Insurance Rate Map (FIRM)] or Flood
Hazard Boundary Map (FHBM) showing the property to be within the SFHA.
Basis of Determination
DHS/FEMA's determination as to whether a structure or legally recorded parcel of land, or portions thereof, described by metes and bounds, may be removed
from the SFHA will be based upon a comparison of the Base (1%-annual-chance) Flood Elevation (BFE) with certain elevation information. The elevation
information required is dependant upon what is to be removed from the SFHA. For Zone A, and AO, please refer to Page 7 of the MT--EZ Form Instructions for
information regarding BFE development in those areas and supporting data requirements.
Determination Requested For: (check one)

Elevation Information Required: (complete item 5)

Structure located on natural grade (LOMA)

Lowest Adjacent Grade to the structure (the elevation of the lowest ground
touching the structure including attached patios, stairs, deck supports or garage)

Legally recorded parcel of land, or portion thereof (LOMA)

Elevation of the lowest ground on the parcel or within the portion of land to be
removed from the SHFA (skip to item 2)

1. PROPERTY INFORMATION Property Description (Lot, and Block Number, Tax Parcel Number, or Abbreviated Description form the Deed, etc.):

2. STRUCTURE INFORMATION Street Address (Including Apt. Unit, Suite, and/or Bldg. No.):

crawl space

1. What is the type of construction? (check one)

slab on grade

basement/enclosure

other (explain)
3. GEOGRAPHIC COORDINATE DATA
Please provide the Latitude and Longitude of the most up stream edge of the structure (in decimal degrees to nearest fifth decimal place)
Lat.
. Long
WGS84
Indicate Datum:
NAD 27
NAD 83

.

Please provide the Latitude and Longitude of the most up stream edge of the property (in decimal degrees to nearst fifth decimal place)
Lat.
. Long.
Indicate Datum:
NAD 83
WGS84
NAD 27

.

4. FLOOD INSURANCE RATE MAP (FRIM) INFORMATION
NFIP Community Number:

Map Panel Number:

Base Flood Elevation (BF): Source of BFE:

5. ELEVATION INFORMATION (SURVEY REQUIRED)
Lowest Adjacent Grade (LAG) to the structure (to the nearest 0.1 foot or meter)

. ft. (m)

Elevation of lowest grade on the property; or within metes and bounds area (to the nearest 0.1 foot or meter)
Indicate the datum (if different from NGVD 29 or NAVD 88 attach datum conversion)
Has DHS/FEMA identified this area as subjected to land subsidence or uplift?

NGVD 29

No

NAVD 88

.

. ft. (m)

Other (Describe):

Yes (provide date of current releveling)

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.
Certifier's Name:

License No.:

Expiration Date:

Company Name:

Telephone No.:

Fax No.:

E-mail
Signature:
FEMA Form 81-92, (2/2011)

Date:

MT-EZ Form Previously FF 81-92

Seal (Optional)
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