FEMA Form 086-0-27 Overview & Concurrence Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0016
Expires February 28, 2014

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, 1800 South Bell Street, Arlington, VA 20958-3005 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.

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).

A. REQUESTED RESPONSE FROM DHS-FEMA
This request is for a: (check one)
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).
LOMR:

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).

B. OVERVIEW
1. The NFIP map panel(s) affected for all impacted communities is (are):
Community Name

Community No.
Ex: 480301
480287

2.

a

State

City of Katy
Harris County

TX
TX

Map No.
48473C
48201C

Panel No.
0005D
0220G

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

Flooding Source:

b. Types of Flooding:

Riverine

Coastal

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

Alluvial fan

Lakes

Other (Attach Description)

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:

FEMA Form 086-0-27, (2/2011)

MT-2 Form 1 Page 1 of 3

a. The basis for this revision request is (check all that apply)

Physical Change

Improved Mehtodology/Data

Regulatory Floodway Revision

Base Map Changes

Coastal Analysis

Hydraulic Analysis

Hydrologic Analysis

Corrections

Weir-Dam Changes

Levee Certification

Alluvial Fan Analysis

Natural Changes

New Topographic Data

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:

Channelization

Levee/Floodwall

Bridge/Culvert

Dam

Fill

Other (Attach Description)

C. REVIEW FEE
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/prevent/fhm/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 that any false statement may be
punishable 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
Signature Of Requester (Required)

Date

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 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 DHS-FEMA, all analyses and documentation used to make this
determination.
Community Official's Name and Title
Mailing Address

Date
Daytime Telephone No.

FAX No.

EMAIL ADDRESS
Community Official's signature (required)

FEMA Form 086-0-27, (2/2011)

Date

MT-2 Form 1 Page 2 of 3

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 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 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.
Date

Signature

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

Required if.....

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/floodwall, 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

FEMA Form 086-0-27, (2/2011)

Seal (optional)

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