Federal Emergency Management Agency
Payment Information Form

Community Name: 

Project Identifier: 

This form must be mailed, along with the appropriate fee, to the address below or faxed to the fax number below.

Type of Request: 

MT-1 application 
MT-2 application 

FEMA
Fee Charge System Administrator
P.O. Box 22787
Alexandria, VA 22304
FAX (703) 317-3076


EDR application 

FEMA Project Library
3601 Eisenhower Avenue
Alexandria, VA 22304
FAX (703) 751-7391

Request No.: (if known) Amount: 

INITIAL FEE* FINAL FEE FEE BALANCE** MASTER CARD VISA CHECK MONEY ORDER 

*Note: Check only for EDR and/or Alluvial Fan requests (as appropriate). 

**Note: Check only if submitting a corrected fee for an ongoing request. 

COMPLETE THIS SECTION ONLY IF PAYING BY CREDIT CARD 

CARD NUMBER 

EXP. DATE 

Month _____ Year _____

Date Signature 

NAME (please print or type) (AS IT APPEARS ON CARD): 

ADDRESS (for your credit card receipt-please print or type) : 

DAYTIME PHONE: