U.S. DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY
COMMUNITY ACKNOWLEDGMENT FORM
O.M.B. NO. 1660-0015
Expires December 31, 2010

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 1.38 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 appears 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, SW, Washington DC 20472, Paperwork Reduction Project (1660-0015).  
Submission of the form is required to obtain or retain benefits under the National Flood Insurance Program.  Please do not send your completed 
survey to the above address.
This form must be completed for requests involving the existing or proposed placement of fill (complete Section A) OR to provide acknowledgment of 
this request to remove a property from the SFHA which was previously located within the regulatory floodway (complete Section B).  
This form must be completed and signed by the official responsible for floodplain management in the community.  The six digit NFIP community 
number and the subject property address must appear in the spaces provided below.  Incomplete submissions may result in processing delays.
Community Number:       		Property Name or Address:       

A.  REQUESTS INVOLVING THE PLACEMENT OF FILL

As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this Letter of Map Revision 
Based on Fill (LOMR-F) or Conditional LOMR-F request.  Based upon the community's review, we find the completed or proposed project meets or is 
designed to meet all of the community floodplain management requirements, including the requirement that no fill be placed in the regulatory floodway, 
and that all necessary Federal, State, and local permits have been, or in the case of a Conditional LOMR-F, will be obtained.  In addition, we have 
determined that the land and any existing or proposed structures to be removed from the SFHA are or will be reasonably safe from flooding as defined in 
44CFR 65.2(c), and that we have available upon request by DHS-FEMA, all analyses and documentation used to make this determination.  For LOMR-F 
requests, we understand that this request is being forwarded to DHS-FEMA for a possible map revision.  For LOMR-F or Conditional LOMR-F requests 
that have the potential to impact an endangered species, documentation will be submitted to show that we have complied with Sections 9 and 10 of the 
Endangered Species Act (ESA).  Section 9 of the ESA prohibits anyone from "taking" or harming an endangered species.  If an action might harm an 
endangered species, a permit is required from U.S. Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA.  For 
actions authorized, funded, or being carried out by Federal or State agencies, documentation from the agency showing its compliance with Section 
7(a)(2) of the ESA will be submitted.

Community Comments:       



Community Official's Name and Title:  (Please Print or Type)
     
Telephone No.:   
     
Community Name:   
     
Community Official's Signature:  (required)


Date:  
     
B.  PROPERTY LOCATED WITHIN THE REGULATORY FLOODWAY

As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this request for a LOMA.  
We understand that this request is being forwarded to DHS-FEMA to determine if this property has been inadvertently included in the regulatory 
floodway.  We acknowledge that no fill on this property has been or will be placed within the designated regulatory floodway.  We find that the completed 
or proposed project meets or is designed to meet all of the community floodplain management requirements.   
Community Comments:       

Community Official's Name and Title:  (Please Print or Type)
     

Telephone No.:   
     
Community Name:  
     
Community Official's Signature (required):  


Date:   
     

DHS - FEMA Form 81-87B, DEC 07	Community Acknowledgment Form	MT-1 Form 3 Page 1 of 1