Form 81-89 Overview and Concurrence Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0016
Expires August 31, 2007

OVERVIEW & CONCURRENCE FORM

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1 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 (1660-0016). 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.
A. REQUESTED RESPONSE FROM FEMA

This request is for a: (check one)
CLOMR: A letter from FEMA commenting on whether a proposed project, if built as proposed, would justify a map revision, or proposed
hydrology changes (See 44 CFR Ch. 1, Parts 60, 65 & 72).
LOMR:

A letter from FEMA officially revising the current NFIP map to show the changes to floodplains, regulatory floodway, or flood elevations.
(See Parts 60 &65 of the NFIP Regulations).
B. OVERVIEW

1. The NFIP map panel(s) affected for all impacted communities is (are):
Community No.

Community No.
Ex: 480301
480287

State

Kale, City
Harris County

TX
TX

Map No.
480301
48201C

Panel No.
0005D
0220G

Effective Date
02/08/83
09/28/90

2. Flooding Source:
3. Project Name/Identifier:
4. FEMA Zone designations affected:

(Choices A, AH, AO, A1-A30, A99, AE, AR, V, V1-V30, VE, B, C, D, X)

5. Basis for Request and Type of Revision:
a. The basis for this revision request is (check all that apply)
Physical Change

Improved Mehtodology/Data

Regulatory Floodway Revision

Other (attach Description)

Note: A photograph and narrative description of the area of concern is not required, but is very helpful during review.
b. The area of revision encompasses the folowing types of flooding and structures (check all that apply).
Riverine

Coastal

Shallow Flooding (e.g., Zones AO and AH)

Alluvial fan

Lakes

Other (Attach Description)

Channelization

Levee/Floodwall

Bridge/Culvert

Dam

Fill

Other (Attach Description)

FEMA Form 81-89, JAN 07

MT-2 Form 1 Page 1 of 2

C. REVIEW FEE

Has the review fee for the appropriate request category been included?

Yes, Fee Amount:

$

No, Attach Explanation

Please see FEMA website at http://fema.gov/mit/tsd/frm_fees.htm for Fee Amounts and Exemptions.
D. SIGNATURE

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 improisonment under Title 18 of the United States code, Section 1001.
Name

Company

Mailing Address

Daytime Telephone No.

FAX No.

EMAIL ADDRESS
Signature Of Requester (Required)

Date

As the community official responsible for floosplain management, I hereby acknowledge that we have received and reviewed this Letter of of Map
Revision (LOMR) or conditional LOMR 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 a LOMR, 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 analyses and documentation used to make this
determination.
Community Official's Name and Title
Community Name

Date
Community Official's signature (required)

Date

CERTIFICATION BY REGISTRATION PROFESSIONAL ENGINEER AND/OR LAND SURVEYOR
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.

Signature

Date

Ensure the forms that are appropriate to your revision request are included in your submittal.
Form name an (Number)

Required if.....

Riverine Hydrology & Hydraulics Form (Form 2)

New or revised discharges or water-surface elevations

Riverine Structures Form (Form 3)

Channel is modified, addition/revision of bridge/culverts,
addition/revision of levee/floodwall, addition/revision of dam

Coastal Analysis Form (Form 4)

New or revised coastal elevations

Coastal Structures Form (Form 5)

Addition/revision of coastal structure

Alluvial Fan Flooding Form (Form 6)

Flood control measures on alluvial fans

FEMA Form 81-89, JAN 07

Seal (optional)

MT-2 Form 1 Page 2 of 2