U.S. DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY
APPLICATION FORM FOR SINGLE RESIDENTIAL LOT OR STRUCTURE AMENDMENTS TO 
NATIONAL FLOOD INSURANCE PROGRAM MAPS
O.M.B. NO. 1660-0037
Expires September 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? 

       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; 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):

   0	Your entire legally recorded property?
0	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.)
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:
     
E-mail address:
     
Mailing Address (include Company name if applicable):
     
     
Daytime Telephone No.:
     

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 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 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 DHS-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 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 Determination

DHS-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 5)
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 Legally recorded parcel of land, or portion thereof (LOMA)
Elevation of the lowest ground on the parcel or within the portion of land  
to be removed from the SFHA
1.   PROPERTY DESCRIPTION (Lot and Block Number, Tax Parcel Number, Legal Description, etc.):

2.	BUILDING INFORMATION  
Building Street Address (including Apt. Unit, Suite, and/or Bldg. No.):
     
What is the type of construction?   (check one)       0 crawl space      0 slab on grade     0 basement/enclosure       
 
0 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:  0  NAD83    0  NAD27               .       Lat.        .       Long.
Please provide the Latitude and Longitude of the most upstream edge of the property (in decimal degrees)
Indicate Datum:  0  NAD83    0  NAD27               .       Lat.        .       Long.
4.	FLOOD INSURANCE RATE MAP (FIRM) INFORMATION
NFIP Community Number:
     
Map & Panel Number:
     
Base Flood Elevation (BFE):
     
Source of BFE:
     
5.	ELEVATION INFORMATION (SURVEY REQUIRED)
*	Lowest Adjacent Grade (LAG) to the structure (to the nearest 0.1 foot or meter)       .         ft. (m)
*	Elevation of the lowest grade on the property; or metes and bounds area (to the nearest 0.1 foot or meter)       .         ft. (m)
*	Indicate the datum (and datum conversion if different from NGVD 29 or NAVD 88)    0  NGVD 29    0  NAVD 88    Other (Describe):       
*	Has FEMA identified this area as subject to land subsidence or uplift?    0  No  0  Yes (provide date of 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 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


FEMA Form 81-92, JUN 07	MT-EZ Form	Page 2 of 3

DHS - FEMA Form 81-92, SEP 07	MT-EZ Form	Page 1 of 3