Form FEMA Form 086-0-26 FEMA Form 086-0-26 Property Information Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

PROPERTY INFORMATION FORM

OMB Control Number: 1660-0015
Expiration: 09/30/2017

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1.63 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 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, 1800 South Bell Street, Arlington, VA 20598-3005 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.
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).
This form may be completed by the property owner, property owner's agent, licensed land surveyor, or registered professional engineer to support a
request for a Letter of Map Amendment (LOMA), Conditional Letter of Map Amendment (CLOMA), Letter of Map Revision Based on Fill (LOMR-F),
or Conditional Letter of Map Revision Based on Fill (CLOMR-F) for existing or proposed, single or multiple lots/structures. In order to process our
request, all information on this form must be completed in its entirety, unless stated as optional. Incomplete submission will result in processing
delays. Please check the item below that describes your request.
A letter from FEMA stating that an existing structure or parcel of land that has not been elevated by fill (natural grade)
LOMA
would not be inundated by the base flood.

CLOMA

A letter from FEMA stating that a proposed structure that is not to be elevated by fill (natural grade) would not be
inundated by the base flood if built as proposed.

LOMR-F

A letter from FEMA stating that an existing structure or parcel of land that has been elevated by fill would not be
inundated by the base flood.

CLOMR-F

A letter from FEMA stating that a parcel or land or proposed structure that will be elevated by fill would not be inundated
by the base flood if fill is placed on the parcel as proposed or the structure is built as proposed.

Fill is defined as material from any source placed to raise the ground to or above the Base Flood Elevation (BFE). The common construction practice
of removing unsuitable existing material (topsoil) and backfill with select structural material is not considered the placement of fill if the practice does
not alter the existing (natural grade) elevation, which is at or above the BFE. Fill that is placed before the date of the first National Flood Insurance
Program (NFIP) map showing the area in a Special Flood Hazard Area (SFHA) is not considered natural grade.
Has fill been placed on your
property?

Yes

No

Will fill be placed on your property?

Yes

No

If yes, when was fill placed?

Month/Year

If yes, when will fill be placed?

Month/Year

* If yes, Endangered Species Act (ESA) compliance must be documented to FEMA prior to issuance of the CLOMR-F determination (please refer

page 4 to the MT-1 instructions

1. Street address of the Property (if requested request is for multiple structures or units please attach additional sheet referencing sheet reference each
address and enter street names before):
2. Legal description of Property (lot, Block, Subdivision or abbreviated description from the Deed):
3. Are you requesting that the flood zone determination be complete for (check one):
Structure on the property? What are the dates of construction? MM/YYYY
A portion of land within the bounds of the property (a certified metes and bounds description and map of the area to be removed, certified by a
licensed land surveyor or registered professional engineer, are required)?
The entire legally recorded property?
4. Is this request for a (Check one):
Single structure
Single lot
Multiple structures

How many structures are involved in your request? List the number:

Multiple lots

How many Lots are involved in your request? List the number:

FEMA FORM 086-0-22 (09/17)

Property Information

MT-1 Form 1 Page 1 of 2

In addition to this form (MT-1 Form 1), please complete the checklist below. ALL requests must include one copy of the following:
Copy of the effective FIRM panel on which the structure and/or property location has been accurately plotted (property inadvertently
located in the NFIP regulatory floodway will require Section B of MIT-1 Form
Copy of the Subdivision Plat Map for the property (with recordation data and stamp of the Recorder's Office)
Copy of the Property Deed (with recordation data and stamp of the Recorder's Office). accomplished by a tax assessor's map or other
certified map showing the surveyed location of the property relative to local street and watercourses. The map should include at least one
street intersection that is shown on the FRIM panel.
Form 2 - Elevation Form. If the request is to remove the structure, and an Elevation Certificate has already been completed for this
property, it may be submitted in lieu of Form 2. If the request is to remove the entire legally recorded property, or a portion thereof, the
lowest lot elevation must be provided on Form 2.
Please included a map scale and North arrow on all maps submitted.
For LOMR-Fs and CLOMR-Fs, the following must be submitted in addition to the items listed above
Form 3 - Community Acknowledgment Form
For CLOMR-Fs, the following must be submitted in addition to the items listed above:
Processing Fee (See instructions for appropriate mailing address for fee submittal; visit www.fema.gov/mit/tsd/frm_fees.htm for the most current fee
schedule)
Revised fee schedules are published periodically, but no more than once annually, as noted in the Federal Register. Please note: single/multiple lot(s)/
structure(s) LOMAs are free exempt. The current review and processing fees are listed below:
Check the fee that applies to your request:
$325 (single lot/structure LOMR-F following a CLOMR-F)
$425 (single lot/structure LOMR-F)
$500 (single lot/structure CLOMA-F, CLOMR-F)
$700 (multiple lot/structure LOMR-F, following a CLOMR-F, or multiple lot/structure CLOMA)
$800 (multiple lot/structure LOMR-F, or CLOMR-F)
Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to: National Flood
Insurance Program.

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.
Please Print or Type
Company:

Applicant's Name:

Mailing Address:

FAX No.:

Signature of Applicant (required)

Date

(Optional)
E-Mail Address:
If you have any questions concerning FEMA policy, or the NFIP in general, please contact the FEMA Map Assistance Center toll free at 1-877FEMA MAP (1-877-336-2627) or visit the Flood Hazard Mapping website at www.fema.gov/mit/tsd.

FEMA FORM 086-0-22 (09/17)

Property Information Form

MT-1 Form 1 Page 2 of 2