For Zones A and AO please refer to Page 7 of the MT-EZ Form Instructions for information regarding BFE development in those areas and supporting data requirements. Certifier s Name License No. Expiration Date Company Name Telephone No. Fax No. Seal optional Email Signature Date In addition to this form MT-EZ please complete the checklist below. Applicant s Name required E-mail address optional By checking here you may receive correspondence electronically at the email address provided Mailing Address include Company name if applicable required Daytime Telephone No. required Fax No. optional Signature of Applicant required Date required End of Section A DHS - FEMA Form 086-0-22 FEB 11 MT-EZ Form Page 1 of 3 B This section must be completed by a registered professional engineer or licensed land surveyor. Incomplete submissions will result in processing delays. For additional information regarding this form including where to obtain the supporting documents listed above please refer to the MT-EZ Form Instructions located at Mail your request to LOMC CLEARINGHOUSE 7390 COCA COLA DRIVE SUITE 204 HANOVER MD 21076 Attn. LOMA Manager FEMA REGIONS. Fema.gov/plan/prevent/fhm/dlmt-1. shtm or call the FEMA Map Information eXchange toll free 877-FEMA MAP 877-336-2627 Legal description of Property Lot Block Subdivision or abbreviated description from the Deed and street address of the Property required Are you requesting that a flood zone determination be completed for check one A structure on your property What is the date of construction MM/YYYY 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. 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. 1660-0015 Expires February 28 2014 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection 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 data needed and completing and submitting this form* This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form* Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to Information Collections Management Department of Homeland Security Federal Emergency Management Agency 1800 South Bell Street Arlington VA 20598-3005 Paperwork Reduction Project 1660-0015 NOTE Do not send your completed form to this address. 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 portion 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.
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