Form 086-0-26B Community Acknowledgement Form

U.S. DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0015

COMMUNITY ACKNOWLEDGMENT FORM

Expires December 31,2010

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 1.38 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 OM8 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 must be completed for requests involving the existing or proposed placement of fill (complete Section A) OR to provide acknowledgment of this request 10
remove a property from the SFHA which was previously located within the regulatory floodway (complete Section 8).
This form musI be completed and signed by the official responsible for floodplain management in the community. The six digit NFIP community number
and the subject property address must appear in the spaces provided below. Incomplete submissions will result in processing delays. Please
refer to the MT-l instructions for additional information about this form.

Community Number: _ _ _ _ _~._ __

Property Name or Address:

A. REQUESTS 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.
For Conditional LOMR-F requests, the applicant has or will document Endangered Species Act
compliance to FEMA prior to issuance of the
that
with Sections 9 and 10 of the ESA has been achieved
ConditionallOMR-F determination. For LOMR-F requests, I
anyone from "taking" or harming an endangered species. If an action might harm
independently of FEMA's process. Section 9 of the ESA
an
species, a permit is required from U.S. Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA.
For actions authorized, funded, or being carried out by Federal or State agencies, documentation from the agency showing its compliance 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
as defined in 44CFR 6S,2(c), and that we have available upon request by DHS-FEMA, all
from the SFHA are or will be reasonably safe from
analyses and documentation used to make this determination. For LOMR-F requests, we understand that this request is being forwarded to DHS­
FEMA for a possible map revision.
Community Comments:

Community Official's Name and Title: (Please Print or

2.

Community Name:

Telephone No.:

3.

Community OffiCial's Signature: (required)

Date:

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 DHS-FEMA to determine if this property has been inadvertently included in the
that no fill on this property has been or will be placed within the
regulatory floodway. We find
regulatory floodway. We
to meet all of the community floodplain management requirements.
that the completed or proposed project meets or is
Community Comments:

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

FF 086-0-26B

Telephone No.:

Community Name :

5.

Community Official's Signature (required):

Date: