FEDERAL EMERGENCY MANAGEMENT AGENCY
APPLICATION FORM FOR SINGLE RESIDENTIAL LOT OR STRUCTURE AMENDMENTS TO 
NATIONAL FLOOD INSURANCE PROGRAM MAPS
O.M.B. NO. 3067-0257
Expires May 31, 2005

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, Federal Emergency Management Agency, 500 C Street, S.W., Washington DC 20472, Paperwork 
Reduction Project (3067-0257).  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 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 
placed to raise 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 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.

1.	Has fill been placed on your property? 

       0    No     0   Yes - If Yes, STOP!! - You must complete the MT-1 application forms; visit 
               http://www.fema.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) and street address of the Property 
        (if different from mailing address):         
          

3.	Are you requesting that the flood zone designation be removed from (check one):

   0	Your entire legally recorded property?
0	A portion of your legally recorded property? (a metes and bounds description and map of the area to be removed,  
certified by a registered professional engineer or licensed land surveyor are required)
0	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 Name:
     
Company:
     
Mailing Address:
     
     
Daytime Telephone No.:
     
E-mail address:
     
Fax No.:
     
Signature of Applicant (required)

Date 
     
End of Section A

B - This section must be completed by a registered professional engineer or licensed land surveyor.   

NOTE:  If an NFIP Elevation Certificate has already been completed for this property, it may be submitted in lieu of this section of the 
form. 

Applicable Regulations

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 administrative procedure whereby FEMA will review information submitted by 
an owner or lessee of property who believes that his or her property has been inadvertently 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 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 Determination

FEMA's determination 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%-annual-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: (check one)
Elevation Information Required: (complete Item 4)
0 Structure located on natural grade (LOMA)
Lowest Adjacent Grade to the structure (the elevation of the lowest  
ground touching the structure including attached decks or garage)
0 Undeveloped legally recorded parcel of land (LOMA)
Elevation of the lowest ground on the parcel or within the portion of land  
to be removed from the SFHA (skip to Item 2)
1.	What is the type of construction?   (check one)       0 crawl space      0 slab on grade     0 basement/enclosure       
 
0 other (explain)      
2.	BUILDING INFORMATION  
Building Street Address (including Apt. Unit, Suite, and/or Bldg. No.):
     
Property Description (Lot and Block Number, Tax Parcel Number, Legal Description, etc.):
     
3.	FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
NFIP Community Number:
     
Map & Panel Number:
     
Base Flood Elevation:
     
4.	ELEVATION INFORMATION (SURVEY REQUIRED)
*	Lowest Adjacent Grade (LAG) to the structure      .      ft. (m)
*	Elevation of the lowest grade on the property; or, metes and bounds area      .      ft. (m)
*	Indicate the datum (and datum conversion if different from NGVD 29 or NAVD 88)       
*	Has FEMA identified this area as subject to land subsidence or uplift?  	0  Yes  0  No   
*	If Yes, what is the date of the current releveling?       

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.  All documents submitted in support of this request are correct to the best of my knowledge.  I understand that any false statement 
may be punishable by fine or imprisonment under Title 18 of the United States Code, Section 1001.
Certifier's Name:
     
License No.:
     
Expiration Date:
     
Seal (optional)

Company Name:
     
Telephone No.:
     
Fax 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 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 

*	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

*	Please include a map scale on all maps submitted

All requests should be submitted to the address shown on the last page of the instructions.

FEMA Form 81-92, MAY 02	MT-EZ Form	Page 2 of 3

FEMA Form 81-92, MAY 02	MT-EZ Form	Page 1 of 3