+--------------------------------------------------------+-------------+
| ### U.S. DEPARTMENT OF H                               | #           |
| OMELAND SECURITY - Federal Emergency Management Agency | *O.M.B. NO. |
|                                                        |  1660-0037* |
| ##                                                     |             |
| Application form for single Residential lot or structu | # *Expir    |
| re amendments to national flood insurance program maps | es Septembe |
|                                                        | r 30, 2010* |
+--------------------------------------------------------+-------------+

+--------------------+------------+-----------+-----------------------+
| PAPERWORK          |            |           |                       |
| REDUCTION ACT      |            |           |                       |
|                    |            |           |                       |
| Public reporting   |            |           |                       |
| burden for this    |            |           |                       |
| form is estimated  |            |           |                       |
| to average 2.4     |            |           |                       |
| 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 is  |            |           |                       |
| displayed 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,      |            |           |                       |
| S.W., Washington   |            |           |                       |
| DC 20472,          |            |           |                       |
| Paperwork          |            |           |                       |
| Reduction Project  |            |           |                       |
| (1660-0037).       |            |           |                       |
| Submission of this |            |           |                       |
| form is required   |            |           |                       |
| to obtain or       |            |           |                       |
| retain benefits    |            |           |                       |
| under the National |            |           |                       |
| Flood Insurance    |            |           |                       |
| Program.           |            |           |                       |
+--------------------+------------+-----------+-----------------------+
| This form should   |            |           |                       |
| be used to request |            |           |                       |
| that the           |            |           |                       |
| Department of      |            |           |                       |
| Homeland           |            |           |                       |
| Security's Federal |            |           |                       |
| Emergency          |            |           |                       |
| Management Agency  |            |           |                       |
| (FEMA) remove a    |            |           |                       |
| single structure   |            |           |                       |
| or legally         |            |           |                       |
| recorded parcel of |            |           |                       |
| land or portions   |            |           |                       |
| thereof, described |            |           |                       |
| by metes and       |            |           |                       |
| bounds, certified  |            |           |                       |
| by a registered    |            |           |                       |
| professional       |            |           |                       |
| engineer or        |            |           |                       |
| licensed land      |            |           |                       |
| surveyor, from a   |            |           |                       |
| designated Special |            |           |                       |
| Flood Hazard Area  |            |           |                       |
| (SFHA), an area    |            |           |                       |
| that would be      |            |           |                       |
| inundated by the   |            |           |                       |
| flood having a     |            |           |                       |
| 1%-chance of being |            |           |                       |
| equaled or         |            |           |                       |
| exceeded in any    |            |           |                       |
| given year (base   |            |           |                       |
| flood), via Letter |            |           |                       |
| of Map Amendment   |            |           |                       |
| (LOMA). It shall   |            |           |                       |
| not be used for    |            |           |                       |
| requests submitted |            |           |                       |
| by developers, for |            |           |                       |
| requests involving |            |           |                       |
| multiple           |            |           |                       |
| structures or      |            |           |                       |
| lots, for property |            |           |                       |
| in alluvial fan    |            |           |                       |
| areas or coastal   |            |           |                       |
| high hazard areas  |            |           |                       |
| (V zones), or      |            |           |                       |
| requests involving |            |           |                       |
| the placement of   |            |           |                       |
| fill. (NOTE: Use   |            |           |                       |
| MT-1 forms for     |            |           |                       |
| such requests).    |            |           |                       |
| Fill is defined as |            |           |                       |
| material from any  |            |           |                       |
| source (including  |            |           |                       |
| the subject        |            |           |                       |
| property) placed   |            |           |                       |
| that raises the    |            |           |                       |
| grade to or above  |            |           |                       |
| the Base Flood     |            |           |                       |
| Elevation (BFE).   |            |           |                       |
| The common         |            |           |                       |
| construction       |            |           |                       |
| practice of        |            |           |                       |
| removing           |            |           |                       |
| unsuitable         |            |           |                       |
| existing material  |            |           |                       |
| (topsoil) and      |            |           |                       |
| backfilling 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.     |            |           |                       |
| Also, fill that is |            |           |                       |
| placed before the  |            |           |                       |
| date of the first  |            |           |                       |
| National Flood     |            |           |                       |
| Insurance Program  |            |           |                       |
| (NFIP) map showing |            |           |                       |
| the area in an     |            |           |                       |
| SFHA is considered |            |           |                       |
| natural grade.     |            |           |                       |
+--------------------+------------+-----------+-----------------------+
| **LOMA:**          | **A letter |           |                       |
|                    | from       |           |                       |
|                    | DHS-FEMA   |           |                       |
|                    | stating    |           |                       |
|                    | that an    |           |                       |
|                    | existing   |           |                       |
|                    | structure  |           |                       |
|                    | or parcel  |           |                       |
|                    | of land    |           |                       |
|                    | that has   |           |                       |
|                    | not been   |           |                       |
|                    | elevated   |           |                       |
|                    | by fill    |           |                       |
|                    | would not  |           |                       |
|                    | be         |           |                       |
|                    | inundated  |           |                       |
|                    | by the     |           |                       |
|                    | base       |           |                       |
|                    | flood.**   |           |                       |
+--------------------+------------+-----------+-----------------------+
| **A -- This        |            |           |                       |
| section may be     |            |           |                       |
| completed by the   |            |           |                       |
| property owner or  |            |           |                       |
| by the property    |            |           |                       |
| owner's agent. In  |            |           |                       |
| order to process   |            |           |                       |
| your request, all  |            |           |                       |
| information on     |            |           |                       |
| this form must be  |            |           |                       |
| completed in its   |            |           |                       |
| entirety.          |            |           |                       |
| Incomplete         |            |           |                       |
| submissions may    |            |           |                       |
| result in          |            |           |                       |
| processing         |            |           |                       |
| delays.**          |            |           |                       |
|                    |            |           |                       |
| 1.  **Has fill     |            |           |                       |
|     been placed on |            |           |                       |
|     your property  |            |           |                       |
|     to raise       |            |           |                       |
|     ground that    |            |           |                       |
|     was previously |            |           |                       |
|     below the      |            |           |                       |
|     BFE?**         |            |           |                       |
|                    |            |           |                       |
| > **No** **Yes --  |            |           |                       |
| > If Yes, STOP!!   |            |           |                       |
| > -- You must      |            |           |                       |
| > complete the     |            |           |                       |
| > MT-1 application |            |           |                       |
| > forms; visit**   |            |           |                       |
| >                  |            |           |                       |
| > [**http://www.fe |            |           |                       |
| ma.gov/plan/preven |            |           |                       |
| t/fhm/dl_mt-1.shtm |            |           |                       |
| **](http://www.fem |            |           |                       |
| a.gov/plan/prevent |            |           |                       |
| /fhm/dl_mt-1.shtm) |            |           |                       |
|                    |            |           |                       |
| **or call the FEMA |            |           |                       |
| Map Assistance     |            |           |                       |
| Center toll free:  |            |           |                       |
| (877-FEMA MAP)     |            |           |                       |
| (877-336-2627)**   |            |           |                       |
|                    |            |           |                       |
| 2.  **Legal        |            |           |                       |
|     description of |            |           |                       |
|     Property (Lot, |            |           |                       |
|     Block,         |            |           |                       |
|     Subdivision;   |            |           |                       |
|     complete       |            |           |                       |
|     description as |            |           |                       |
|     it appears in  |            |           |                       |
|     the Deed is    |            |           |                       |
|     not necessary) |            |           |                       |
|     and street     |            |           |                       |
|     address of the |            |           |                       |
|     Property:**    |            |           |                       |
|                    |            |           |                       |
|                    |            |           |                       |
|                    |            |           |                       |
| **3. Are you       |            |           |                       |
| requesting that    |            |           |                       |
| the flood zone     |            |           |                       |
| designation be     |            |           |                       |
| removed from       |            |           |                       |
| (check one):**     |            |           |                       |
|                    |            |           |                       |
| **Your entire      |            |           |                       |
| legally recorded   |            |           |                       |
| property?**        |            |           |                       |
|                    |            |           |                       |
| > **A portion of   |            |           |                       |
| > your legally     |            |           |                       |
| > recorded         |            |           |                       |
| > property? (A     |            |           |                       |
| > certified metes  |            |           |                       |
| > and bounds       |            |           |                       |
| > description and  |            |           |                       |
| > map of the area  |            |           |                       |
| > to be removed,\  |            |           |                       |
| > certified by a   |            |           |                       |
| > registered       |            |           |                       |
| > professional     |            |           |                       |
| > engineer or      |            |           |                       |
| > licensed land    |            |           |                       |
| > surveyor are     |            |           |                       |
| > required. For    |            |           |                       |
| > the preferred    |            |           |                       |
| > format of metes  |            |           |                       |
| > and bounds       |            |           |                       |
| > descriptions,    |            |           |                       |
| > please refer to  |            |           |                       |
| > the MT-EZ        |            |           |                       |
| > Instructions.)** |            |           |                       |
| >                  |            |           |                       |
| > **A structure on |            |           |                       |
| > your property?   |            |           |                       |
| > What is the date |            |           |                       |
| > of               |            |           |                       |
| > construction?**  |            |           |                       |
| >                  |            |           |                       |
+--------------------+------------+-----------+-----------------------+
| **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.**            |            |           |                       |
+--------------------+------------+-----------+-----------------------+
| **Applicant's      |            | **E-mail  |                       |
| Name:**            |            | a         |                       |
|                    |            | ddress:** |                       |
|                    |            |           |                       |
|                    |            |           |                       |
+--------------------+------------+-----------+-----------------------+
| **Mailing Address  |            | **Daytime |                       |
| (include Company   |            | Telephone |                       |
| name if            |            | No.:**    |                       |
| applicable):**     |            |           |                       |
|                    |            |           |                       |
|                    |            |           |                       |
|                    |            |           |                       |
|                    |            |           |                       |
+--------------------+------------+-----------+-----------------------+
|                    |            | **Fax     |                       |
|                    |            | No.:**    |                       |
|                    |            |           |                       |
|                    |            |           |                       |
+--------------------+------------+-----------+-----------------------+
| **Signature of     |            |           | **Date\               |
| Applicant          |            |           | **                    |
| (required)**       |            |           |                       |
+--------------------+------------+-----------+-----------------------+
| **End of Section   |            |           |                       |
| A**                |            |           |                       |
+--------------------+------------+-----------+-----------------------+

+--------------+------+-------+---+---+-------+-----+----------------+
| **B -- This  |      |       |   |   |       |     |                |
| section must |      |       |   |   |       |     |                |
| be completed |      |       |   |   |       |     |                |
| by a         |      |       |   |   |       |     |                |
| registered   |      |       |   |   |       |     |                |
| professional |      |       |   |   |       |     |                |
| engineer or  |      |       |   |   |       |     |                |
| licensed     |      |       |   |   |       |     |                |
| land         |      |       |   |   |       |     |                |
| surveyor.\   |      |       |   |   |       |     |                |
| **           |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| > **NOTE: If |      |       |   |   |       |     |                |
| > the        |      |       |   |   |       |     |                |
| > request is |      |       |   |   |       |     |                |
| > to remove  |      |       |   |   |       |     |                |
| > the        |      |       |   |   |       |     |                |
| > structure, |      |       |   |   |       |     |                |
| > and an     |      |       |   |   |       |     |                |
| > Elevation  |      |       |   |   |       |     |                |
| >            |      |       |   |   |       |     |                |
|  Certificate |      |       |   |   |       |     |                |
| > has been   |      |       |   |   |       |     |                |
| > completed  |      |       |   |   |       |     |                |
| > for this   |      |       |   |   |       |     |                |
| > property,  |      |       |   |   |       |     |                |
| > it may be  |      |       |   |   |       |     |                |
| > submitted  |      |       |   |   |       |     |                |
| > in lieu of |      |       |   |   |       |     |                |
| > Section B. |      |       |   |   |       |     |                |
| > If the     |      |       |   |   |       |     |                |
| > request is |      |       |   |   |       |     |                |
| > to remove  |      |       |   |   |       |     |                |
| > the entire |      |       |   |   |       |     |                |
| > legally    |      |       |   |   |       |     |                |
| > recorded   |      |       |   |   |       |     |                |
| > property,  |      |       |   |   |       |     |                |
| > or a       |      |       |   |   |       |     |                |
| > portion    |      |       |   |   |       |     |                |
| > thereof,   |      |       |   |   |       |     |                |
| > the lowest |      |       |   |   |       |     |                |
| > elevation  |      |       |   |   |       |     |                |
| > on the lot |      |       |   |   |       |     |                |
| > or         |      |       |   |   |       |     |                |
| > described  |      |       |   |   |       |     |                |
| > portion    |      |       |   |   |       |     |                |
| > must be    |      |       |   |   |       |     |                |
| > provided   |      |       |   |   |       |     |                |
| > in Section |      |       |   |   |       |     |                |
| > B.**       |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| **Applicable |      |       |   |   |       |     |                |
| R            |      |       |   |   |       |     |                |
| egulations** |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| The          |      |       |   |   |       |     |                |
| regulations  |      |       |   |   |       |     |                |
| pertaining   |      |       |   |   |       |     |                |
| to LOMAs are |      |       |   |   |       |     |                |
| presented in |      |       |   |   |       |     |                |
| the National |      |       |   |   |       |     |                |
| Flood        |      |       |   |   |       |     |                |
| Insurance    |      |       |   |   |       |     |                |
| Program      |      |       |   |   |       |     |                |
| (NFIP)       |      |       |   |   |       |     |                |
| regulations  |      |       |   |   |       |     |                |
| under Title  |      |       |   |   |       |     |                |
| 44, Chapter  |      |       |   |   |       |     |                |
| I, Parts 70  |      |       |   |   |       |     |                |
| and 72, Code |      |       |   |   |       |     |                |
| of Federal   |      |       |   |   |       |     |                |
| Regulations. |      |       |   |   |       |     |                |
| The purpose  |      |       |   |   |       |     |                |
| of Part 70   |      |       |   |   |       |     |                |
| is to        |      |       |   |   |       |     |                |
| provide an   |      |       |   |   |       |     |                |
| ad           |      |       |   |   |       |     |                |
| ministrative |      |       |   |   |       |     |                |
| procedure    |      |       |   |   |       |     |                |
| whereby      |      |       |   |   |       |     |                |
| DHS-FEMA     |      |       |   |   |       |     |                |
| will review  |      |       |   |   |       |     |                |
| information  |      |       |   |   |       |     |                |
| submitted by |      |       |   |   |       |     |                |
| an owner or  |      |       |   |   |       |     |                |
| lessee of    |      |       |   |   |       |     |                |
| property who |      |       |   |   |       |     |                |
| believes     |      |       |   |   |       |     |                |
| that his or  |      |       |   |   |       |     |                |
| her property |      |       |   |   |       |     |                |
| has been     |      |       |   |   |       |     |                |
| i            |      |       |   |   |       |     |                |
| nadvertently |      |       |   |   |       |     |                |
| included in  |      |       |   |   |       |     |                |
| a designated |      |       |   |   |       |     |                |
| SFHA. The    |      |       |   |   |       |     |                |
| necessity of |      |       |   |   |       |     |                |
| Part 70 is   |      |       |   |   |       |     |                |
| due in part  |      |       |   |   |       |     |                |
| to the       |      |       |   |   |       |     |                |
| technical    |      |       |   |   |       |     |                |
| difficulty   |      |       |   |   |       |     |                |
| of           |      |       |   |   |       |     |                |
| accurately   |      |       |   |   |       |     |                |
| delineating  |      |       |   |   |       |     |                |
| the SFHA     |      |       |   |   |       |     |                |
| boundary on  |      |       |   |   |       |     |                |
| an NFIP map. |      |       |   |   |       |     |                |
| Part 70      |      |       |   |   |       |     |                |
| procedures   |      |       |   |   |       |     |                |
| shall not    |      |       |   |   |       |     |                |
| apply if the |      |       |   |   |       |     |                |
| topography   |      |       |   |   |       |     |                |
| has been     |      |       |   |   |       |     |                |
| altered to   |      |       |   |   |       |     |                |
| raise the    |      |       |   |   |       |     |                |
| original     |      |       |   |   |       |     |                |
| ground to or |      |       |   |   |       |     |                |
| above the    |      |       |   |   |       |     |                |
| BFE since    |      |       |   |   |       |     |                |
| the          |      |       |   |   |       |     |                |
| effective    |      |       |   |   |       |     |                |
| date of the  |      |       |   |   |       |     |                |
| first NFIP   |      |       |   |   |       |     |                |
| map \[e.g.,  |      |       |   |   |       |     |                |
| a Flood      |      |       |   |   |       |     |                |
| Insurance    |      |       |   |   |       |     |                |
| Rate Map     |      |       |   |   |       |     |                |
| (FIRM) or    |      |       |   |   |       |     |                |
| Flood Hazard |      |       |   |   |       |     |                |
| Boundary Map |      |       |   |   |       |     |                |
| (FHBM)\]     |      |       |   |   |       |     |                |
| showing the  |      |       |   |   |       |     |                |
| property to  |      |       |   |   |       |     |                |
| be within    |      |       |   |   |       |     |                |
| the SFHA.    |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| **Basis of   |      |       |   |   |       |     |                |
| Det          |      |       |   |   |       |     |                |
| ermination** |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| DHS-FEMA's   |      |       |   |   |       |     |                |
| d            |      |       |   |   |       |     |                |
| etermination |      |       |   |   |       |     |                |
| as to        |      |       |   |   |       |     |                |
| whether a    |      |       |   |   |       |     |                |
| structure or |      |       |   |   |       |     |                |
| legally      |      |       |   |   |       |     |                |
| recorded     |      |       |   |   |       |     |                |
| parcel of    |      |       |   |   |       |     |                |
| land, or     |      |       |   |   |       |     |                |
| portions     |      |       |   |   |       |     |                |
| thereof,     |      |       |   |   |       |     |                |
| described by |      |       |   |   |       |     |                |
| metes and    |      |       |   |   |       |     |                |
| bounds, may  |      |       |   |   |       |     |                |
| be removed   |      |       |   |   |       |     |                |
| from the     |      |       |   |   |       |     |                |
| SFHA will be |      |       |   |   |       |     |                |
| based upon a |      |       |   |   |       |     |                |
| comparison   |      |       |   |   |       |     |                |
| of the Base  |      |       |   |   |       |     |                |
| (1%-an       |      |       |   |   |       |     |                |
| nual-chance) |      |       |   |   |       |     |                |
| Flood        |      |       |   |   |       |     |                |
| Elevation    |      |       |   |   |       |     |                |
| (BFE) with   |      |       |   |   |       |     |                |
| certain      |      |       |   |   |       |     |                |
| elevation    |      |       |   |   |       |     |                |
| information. |      |       |   |   |       |     |                |
| For Zone A,  |      |       |   |   |       |     |                |
| with no BFE  |      |       |   |   |       |     |                |
| determined,  |      |       |   |   |       |     |                |
| refer to     |      |       |   |   |       |     |                |
| *Managing    |      |       |   |   |       |     |                |
| Floodplain   |      |       |   |   |       |     |                |
| Development  |      |       |   |   |       |     |                |
| in           |      |       |   |   |       |     |                |
| Approximate  |      |       |   |   |       |     |                |
| Zone A       |      |       |   |   |       |     |                |
| Areas, A     |      |       |   |   |       |     |                |
| Guide for    |      |       |   |   |       |     |                |
| Obtaining    |      |       |   |   |       |     |                |
| and          |      |       |   |   |       |     |                |
| Developing   |      |       |   |   |       |     |                |
| Base         |      |       |   |   |       |     |                |
| (100-Year)   |      |       |   |   |       |     |                |
| Flood        |      |       |   |   |       |     |                |
| Elevations*. |      |       |   |   |       |     |                |
| The          |      |       |   |   |       |     |                |
| elevation    |      |       |   |   |       |     |                |
| information  |      |       |   |   |       |     |                |
| required is  |      |       |   |   |       |     |                |
| dependent on |      |       |   |   |       |     |                |
| whether a    |      |       |   |   |       |     |                |
| structure,   |      |       |   |   |       |     |                |
| or a legally |      |       |   |   |       |     |                |
| recorded     |      |       |   |   |       |     |                |
| parcel of    |      |       |   |   |       |     |                |
| land, is to  |      |       |   |   |       |     |                |
| be removed   |      |       |   |   |       |     |                |
| from the     |      |       |   |   |       |     |                |
| SFHA.        |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| **Item to be |      |       |   | * |       |     |                |
| Removed from |      |       |   | * |       |     |                |
| the SFHA:    |      |       |   | E |       |     |                |
| (check       |      |       |   | l |       |     |                |
| one)**       |      |       |   | e |       |     |                |
|              |      |       |   | v |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | I |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | f |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | m |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | R |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | q |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | : |       |     |                |
|              |      |       |   | ( |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | m |       |     |                |
|              |      |       |   | p |       |     |                |
|              |      |       |   | l |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | I |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | m |       |     |                |
|              |      |       |   | 5 |       |     |                |
|              |      |       |   | ) |       |     |                |
|              |      |       |   | * |       |     |                |
|              |      |       |   | * |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| Structure    |      |       |   | L |       |     |                |
| located on   |      |       |   | o |       |     |                |
| natural      |      |       |   | w |       |     |                |
| grade (LOMA) |      |       |   | e |       |     |                |
|              |      |       |   | s |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | A |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | j |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | G |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | s |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | ( |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | l |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | v |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | f |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | l |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | w |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | s |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | \ |       |     |                |
|              |      |       |   | g |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | g |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | s |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | l |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | g |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | k |       |     |                |
|              |      |       |   | s |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | g |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | g |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | ) |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| Legally      |      |       |   | E |       |     |                |
| recorded     |      |       |   | l |       |     |                |
| parcel of    |      |       |   | e |       |     |                |
| land, or     |      |       |   | v |       |     |                |
| portion      |      |       |   | a |       |     |                |
| thereof      |      |       |   | t |       |     |                |
| (LOMA)       |      |       |   | i |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | f |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | l |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | w |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | s |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | g |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | u |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | p |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | c |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | l |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | w |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | p |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | i |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | f |       |     |                |
|              |      |       |   | l |       |     |                |
|              |      |       |   | a |       |     |                |
|              |      |       |   | n |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | \ |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | b |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | m |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | v |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | d |       |     |                |
|              |      |       |   | f |       |     |                |
|              |      |       |   | r |       |     |                |
|              |      |       |   | o |       |     |                |
|              |      |       |   | m |       |     |                |
|              |      |       |   | t |       |     |                |
|              |      |       |   | h |       |     |                |
|              |      |       |   | e |       |     |                |
|              |      |       |   | S |       |     |                |
|              |      |       |   | F |       |     |                |
|              |      |       |   | H |       |     |                |
|              |      |       |   | A |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| **1.**       |      |       |   |   |       |     |                |
| **PROPERTY   |      |       |   |   |       |     |                |
| D            |      |       |   |   |       |     |                |
| ESCRIPTION** |      |       |   |   |       |     |                |
| (Lot and     |      |       |   |   |       |     |                |
| Block        |      |       |   |   |       |     |                |
| Number, Tax  |      |       |   |   |       |     |                |
| Parcel       |      |       |   |   |       |     |                |
| Number,      |      |       |   |   |       |     |                |
| Legal        |      |       |   |   |       |     |                |
| Description, |      |       |   |   |       |     |                |
| etc.):       |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| **     **    |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| **2.         |      |       |   |   |       |     |                |
| Building     |      |       |   |   |       |     |                |
| I            |      |       |   |   |       |     |                |
| nformation** |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| Building     |      |       |   |   |       |     |                |
| Street       |      |       |   |   |       |     |                |
| Address      |      |       |   |   |       |     |                |
| (including   |      |       |   |   |       |     |                |
| Apt. Unit,   |      |       |   |   |       |     |                |
| Suite,       |      |       |   |   |       |     |                |
| and/or Bldg. |      |       |   |   |       |     |                |
| No.):        |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| What is the  |      |       |   |   |       |     |                |
| type of      |      |       |   |   |       |     |                |
| c            |      |       |   |   |       |     |                |
| onstruction? |      |       |   |   |       |     |                |
| (check one)  |      |       |   |   |       |     |                |
| crawl space  |      |       |   |   |       |     |                |
| slab on      |      |       |   |   |       |     |                |
| grade        |      |       |   |   |       |     |                |
| basemen      |      |       |   |   |       |     |                |
| t/enclosure\ |      |       |   |   |       |     |                |
| \            |      |       |   |   |       |     |                |
| other        |      |       |   |   |       |     |                |
| (explain)    |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| **3.         |      |       |   |   |       |     |                |
| GEOGRAPHIC   |      |       |   |   |       |     |                |
| COORDINATE   |      |       |   |   |       |     |                |
| DATA**       |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| Please       |      |       |   |   |       |     |                |
| provide the  |      |       |   |   |       |     |                |
| Latitude and |      |       |   |   |       |     |                |
| Longitude of |      |       |   |   |       |     |                |
| the most     |      |       |   |   |       |     |                |
| upstream     |      |       |   |   |       |     |                |
| edge of the  |      |       |   |   |       |     |                |
| structure    |      |       |   |   |       |     |                |
| (in decimal  |      |       |   |   |       |     |                |
| degrees)     |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| > Indicate   |      |       |   |   |       |     |                |
| > Datum:     |      |       |   |   |       |     |                |
| > NAD83      |      |       |   |   |       |     |                |
| > NAD27      |      |       |   |   |       |     |                |
| >            |      |       |   |   |       |     |                |
|   **.**      |      |       |   |   |       |     |                |
| > Lat.       |      |       |   |   |       |     |                |
| >            |      |       |   |   |       |     |                |
|   **.**      |      |       |   |   |       |     |                |
| > Long.      |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| Please       |      |       |   |   |       |     |                |
| provide the  |      |       |   |   |       |     |                |
| Latitude and |      |       |   |   |       |     |                |
| Longitude of |      |       |   |   |       |     |                |
| the most     |      |       |   |   |       |     |                |
| upstream     |      |       |   |   |       |     |                |
| edge of the  |      |       |   |   |       |     |                |
| property (in |      |       |   |   |       |     |                |
| decimal      |      |       |   |   |       |     |                |
| degrees)     |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| > Indicate   |      |       |   |   |       |     |                |
| > Datum:     |      |       |   |   |       |     |                |
| > NAD83      |      |       |   |   |       |     |                |
| > NAD27      |      |       |   |   |       |     |                |
| >            |      |       |   |   |       |     |                |
|   **.**      |      |       |   |   |       |     |                |
| > Lat.       |      |       |   |   |       |     |                |
| >            |      |       |   |   |       |     |                |
|   **.**      |      |       |   |   |       |     |                |
| > Long.      |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| **4. FLOOD   |      |       |   |   |       |     |                |
| INSURANCE    |      |       |   |   |       |     |                |
| RATE MAP     |      |       |   |   |       |     |                |
| (FIRM)       |      |       |   |   |       |     |                |
| I            |      |       |   |   |       |     |                |
| NFORMATION** |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| NFIP         | Map  |       | B |   |       | Sou |                |
| Community    | &    |       | a |   |       | rce |                |
| Number:      | P    |       | s |   |       | of  |                |
|              | anel |       | e |   |       | B   |                |
|              | Num  |       | F |   |       | FE: |                |
|              | ber: |       | l |   |       |     |                |
|              |      |       | o |   |       |     |                |
|              |      |       | o |   |       |     |                |
|              |      |       | d |   |       |     |                |
|              |      |       | E |   |       |     |                |
|              |      |       | l |   |       |     |                |
|              |      |       | e |   |       |     |                |
|              |      |       | v |   |       |     |                |
|              |      |       | a |   |       |     |                |
|              |      |       | t |   |       |     |                |
|              |      |       | i |   |       |     |                |
|              |      |       | o |   |       |     |                |
|              |      |       | n |   |       |     |                |
|              |      |       | ( |   |       |     |                |
|              |      |       | B |   |       |     |                |
|              |      |       | F |   |       |     |                |
|              |      |       | E |   |       |     |                |
|              |      |       | ) |   |       |     |                |
|              |      |       | : |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| **5.         |      |       |   |   |       |     |                |
| elevation    |      |       |   |   |       |     |                |
| information  |      |       |   |   |       |     |                |
| (survey      |      |       |   |   |       |     |                |
| required)**  |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| -   Lowest   |      |       |   |   |       |     |                |
|     Adjacent |      |       |   |   |       |     |                |
|     Grade    |      |       |   |   |       |     |                |
|     (LAG) to |      |       |   |   |       |     |                |
|     the      |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|    structure |      |       |   |   |       |     |                |
|     (to the  |      |       |   |   |       |     |                |
|     nearest  |      |       |   |   |       |     |                |
|     0.1 foot |      |       |   |   |       |     |                |
|     or       |      |       |   |   |       |     |                |
|     meter)   |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|   **.**      |      |       |   |   |       |     |                |
|     ft. (m)  |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| ```{=html}   |      |       |   |   |       |     |                |
| <!-- -->     |      |       |   |   |       |     |                |
| ```          |      |       |   |   |       |     |                |
| -            |      |       |   |   |       |     |                |
|    Elevation |      |       |   |   |       |     |                |
|     of the   |      |       |   |   |       |     |                |
|     lowest   |      |       |   |   |       |     |                |
|     grade on |      |       |   |   |       |     |                |
|     the      |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|    property; |      |       |   |   |       |     |                |
|     or metes |      |       |   |   |       |     |                |
|     and      |      |       |   |   |       |     |                |
|     bounds   |      |       |   |   |       |     |                |
|     area (to |      |       |   |   |       |     |                |
|     the      |      |       |   |   |       |     |                |
|     nearest  |      |       |   |   |       |     |                |
|     0.1 foot |      |       |   |   |       |     |                |
|     or       |      |       |   |   |       |     |                |
|     meter)   |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|   **.**      |      |       |   |   |       |     |                |
|     ft. (m)  |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| ```{=html}   |      |       |   |   |       |     |                |
| <!-- -->     |      |       |   |   |       |     |                |
| ```          |      |       |   |   |       |     |                |
| -   Indicate |      |       |   |   |       |     |                |
|     the      |      |       |   |   |       |     |                |
|     datum    |      |       |   |   |       |     |                |
|     (and     |      |       |   |   |       |     |                |
|     datum    |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|   conversion |      |       |   |   |       |     |                |
|     if       |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|    different |      |       |   |   |       |     |                |
|     from     |      |       |   |   |       |     |                |
|     NGVD 29  |      |       |   |   |       |     |                |
|     or       |      |       |   |   |       |     |                |
|     NAVD 88) |      |       |   |   |       |     |                |
|     NGVD 29  |      |       |   |   |       |     |                |
|     NAVD 88  |      |       |   |   |       |     |                |
|     Other    |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|  (Describe): |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| -   Has FEMA |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|   identified |      |       |   |   |       |     |                |
|     this     |      |       |   |   |       |     |                |
|     area as  |      |       |   |   |       |     |                |
|     subject  |      |       |   |   |       |     |                |
|     to land  |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|   subsidence |      |       |   |   |       |     |                |
|     or       |      |       |   |   |       |     |                |
|     uplift?  |      |       |   |   |       |     |                |
|     No Yes   |      |       |   |   |       |     |                |
|     (provide |      |       |   |   |       |     |                |
|     date of  |      |       |   |   |       |     |                |
|     current  |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|  releveling) |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
| This         |      |       |   |   |       |     |                |
| c            |      |       |   |   |       |     |                |
| ertification |      |       |   |   |       |     |                |
| is to be     |      |       |   |   |       |     |                |
| signed and   |      |       |   |   |       |     |                |
| sealed by a  |      |       |   |   |       |     |                |
| licensed     |      |       |   |   |       |     |                |
| land         |      |       |   |   |       |     |                |
| surveyor,    |      |       |   |   |       |     |                |
| registered   |      |       |   |   |       |     |                |
| professional |      |       |   |   |       |     |                |
| engineer, or |      |       |   |   |       |     |                |
| architect    |      |       |   |   |       |     |                |
| authorized   |      |       |   |   |       |     |                |
| by law to    |      |       |   |   |       |     |                |
| certify      |      |       |   |   |       |     |                |
| elevation    |      |       |   |   |       |     |                |
| information. |      |       |   |   |       |     |                |
| 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  |      | Li    |   |   | Expir |     | Seal           |
| Name:        |      | cense |   |   | ation |     | (optional)     |
|              |      | No.:  |   |   | Date: |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| Company      |      | Tele  |   |   | Fax   |     |                |
| Name:        |      | phone |   |   | No.:  |     |                |
|              |      | No.:  |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| Signature:   |      |       |   |   | Date: |     |                |
|              |      |       |   |   |       |     |                |
|              |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+
| (See         |      |       |   |   |       |     |                |
| attached     |      |       |   |   |       |     |                |
| address      |      |       |   |   |       |     |                |
| listing for  |      |       |   |   |       |     |                |
| LOMAs)       |      |       |   |   |       |     |                |
+--------------+------+-------+---+---+-------+-----+----------------+

+-----------------------------------------------------------------------+
| In addition to this form (MT-EZ), **ALL** requests must include the   |
| following:                                                            |
|                                                                       |
| -   Copy of the effective FIRM panel and/or Flood Boundary and        |
|     Floodway Map (FBFM) (if applicable) on which the property         |
|     location has been accurately plotted                              |
|                                                                       |
| -   Copy of the Subdivision Plat Map (with recordation data and stamp |
|     of the Recorder's Office)                                         |
|                                                                       |
| > **OR**                                                              |
| >                                                                     |
| > Copy of the Property Deed (with recordation data and stamp of the   |
| > Recorder's Office), accompanied by a tax assessor's map or other    |
| > certified map showing the surveyed location of the property         |
| > relative to local streets and watercourses                          |
|                                                                       |
| -   Please include a map scale on all maps submitted                  |
+-----------------------------------------------------------------------+
| > **Mail your request to...**                                         |
+-----------------------------------------------------------------------+
| **FEMA National service provider**                                    |
|                                                                       |
| **3601 Eisenhower Avenue**                                            |
|                                                                       |
| **Alexandria, VA 22304-6425**                                         |
|                                                                       |
| **Attn.: loma Manager**                                               |
+-----------------------------------------------------------------------+
| ![](media/image1.png){width="5.520138888888889in"                     |
| height="3.279861111111111in"}                                         |
+-----------------------------------------------------------------------+