Form FEMA Form 086-0-27 FEMA Form 086-0-27 Overview & Concurrence Form

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OVERVIEW & CONCURRENCE FORM

OMB Control Number: 1660-0016
Expiration: 4/30/2017

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.
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). All CLOMRs require documentation of compliance with the
Endangered Species Act. Refer to the Instructions for details.

DRAFT

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 No.

2.

Community Name

State

Map No.

Panel No.

Effective Date

a. 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 (choices: A, AH, AO, A1-A30, A99, AE, AR, V, V1-V30, VE, B, C, D, X)
a. Effective:
b. Revised:

FEMA FORM 086-0-27 (05/17)

MT-2 FORM 1

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

Improved Methodology/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:

6.

Channelization

Levee/Floodwall

Bridge/Culvert

Dam

Fill

Other (Attach Description)

Documentation of ESA compliance is submitted (required to initiate CLOMR review). Please refer to the instructions for more
information.
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 Web site at http://www.fema.gov/forms-documents-and-software/flood-map-related-fees for Fee
Amounts and Exemptions.

DRAFT
D. SIGNATURES

1. REQUESTOR'S 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:

Fax No.:

E-mail Address:
Date:
Signature of Requestor (required):
2. COMMUNITY CONCURRENCE
As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this Letter 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 conditional LOMR, will be obtained. For Conditional LOMR requests, the applicant has documented
Endangered Species Act (ESA) compliance to FEMA prior to FEMA's review of the Conditional LOMR application. For LOMR requests, 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 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 from the SFHA are or will be reasonably safe from flooding as defined in
44CFR 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:
Mailing Address:

Community Name:
Daytime Telephone:

Fax No.:

E-mail Address:
Community Official's Signature (required):
FEMA FORM 086-0-27 (05/17)

Date:
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3. CERTIFICATION BY REGISTERED 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.:
Mailing Address:

Company Name:
Telephone No.:

Expiration Date:

Fax No.:

E-mail Address:
Signature:

Date:

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

Required if …

Riverine Hydrology and Hydraulics Form (Form 2)

New or revised discharges or watersurface 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)

DRAFT

Alluvial Fan Flooding Form (Form 6)

FEMA FORM 086-0-27 (05/17)

Addition/revision of coastal structure

Flood control measures on alluvial fans

Seal (Optional)

MT-2 FORM 1

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