086-0-27 Overview and Concurrence Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0016
Expires December 31, 2010

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 it displays a valid OMB control number. 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 DHS-FEMA
This request is for a: (check one)

o
o

CLOMR: A letter from DHS-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).
A letter from DHS-FEMA officially revising the current NFIP map to show the changes to floodplains, regulatory floodway, or
flood elevations. (See 44 CFR Ch. 1, Parts 60 , 65 & 72).

LOMR:

B. OVERVIEW
1. The NFIP map panel(s) affected for all impacted communities is (are):
Community No.
Example 480301
480287

2.

a

Community Name

State

City of Kathy
Harris County

TX

TX

Map No.
8473C
48201C

Effective
Date

Panel No.
0375E
0220L

02/18/2009
06/18/2007

Flooding Source:

o
o

b. Types of Flooding:

Riverine
Alluvial fan

o
o

o
o

Coastal
Lakes

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

3. Project Namelldentifier:
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)

0

Physical Change

0

Improved Methodology/Data

0
0
0

Coastal Analysis

0

Hydraulic Analysis

Weir-Dam Changes

0
0

Levee Certification

New Topographic Data

0
0
0

Regulatory Floodway
Revision
Hydrologic Analysis

0
0

Corrections

Alluvial Fan Analysis

0

Natural Changes

Base Map Changes

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 following structures (check all that apply)
Structures:

6.

0

0
0

Channelization
Dam

o
o

Levee/Floodwall
Fill

o
o

Bridge/Culvert
Other (Attach Description)

Documentation of ESA compliance is submitted (required to initiate CLOMR review) . Please refer to the instructions for more information.

DHS/FEMA Form 086-0-27, AUG 2010

PREVIOUSLY FF81-89

MT-2 Form 1

Page 1 of 2

C. REVIEW FEE

D
D

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

Yes, Fee Amount:

$_ _ _ _ __

No, Attach Explanation

Please see the DHS-FEMA website at http://fema.gov/plan/preyentlfhm/frm fees.shtm 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 th at any false statement may be
pun ishable by fine or imprisonment under Title 18 of the United States code , Section 1001.
Name

Company

Mailing Address

Daytime Telephone No.

FAX No.

EMAIL ADDRESS

Date

Signature Of Requester (Required)

As the community official responsible for floodplain 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 requirements for when fill is placed in the regulatory
floodway, and that all necessary Federal, State , and local permits have been, or in the case of a conditiona l a LOMR , will be obtained . For
Conditional LOMR requests, the applican t has documented Endangered Species Act (ESA) compliance to FEMA prior to FEMA's review of the
Conditional LOMR application . For LOMR request, I acknowledge that compliance with Sections 9 and 10 of the ESA has been achieved
independently of FEMA's process. For actions authorized, funded , or being carried out by Federal or State agencies, documentation from the
agency showing its comp liance with Section 7(a)(2) of the ESA will be submitted . 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 44CFR 65 .2(c), and that we have
availab le upon request by FEMA, all analyses and documentation used to make this determination
Community Official's Name and Title

Date

Daytime Telephone No .

Mailing Address

FAX No .

EMAIL ADDRESS

Community Official's signature (required)

Date

CEBliEICAIIQr-I ElY BEGISlRAIIQr-I ~BQEESSIQt:lA!. E~Glr-I EE B A~D/QB !.A~D SUBY'!;YQB
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 data , hydrologic and hydraulic analysis , and any other supporting information as per NFIP regulations paragraph 65 .2(b) and
as described in the MT-2 Forms Instructions. All documents submitted in support of this request are correct to the best of my knowledge . I
understand that any fa lse 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

IE-Mail Address

Ensure the forms that are appropriate to your revision request are included in your submittal.
Form name a!]d

D
D
D

o
o

(Numb~rl

Be!:luired it.""

Riverine Hydrology & Hydraulics Form (Form 2)

New or revised discharges or water-surface elevations

Riverine Structures Form (Form 3)
Coastal Analysis Form (Form 4)

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

DHS/FEMA Form 086-0-27, AUG 2010

PREVIOUSLY FF81 -89

Seal (opti onal)

MT-2 Form 1

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