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:




        	0 MT-1 application 
     	0 MT-2 application 
        
        
        
      
      
     	0 EDR application
        
        
  
  
  Request No.:        		(if known)		Amount:       	

0  INITIAL FEE*  0   FINAL FEE  0   FEE BALANCE**  0   MASTER CARD  0   VISA  0   CHECK   0   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 
  
 
 
 
 
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                                                    _________________________________________________________________
Date                                                                                                                   Signature


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

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

DAYTIME PHONE:        				


FEMA Form 81-107	Payment Information Form