FEMA Project Library 

847 South Pickett Street 

Alexandria, VA 22304-4605 

FAX (703) 212-4090 

LOMC Clearinghouse 

847 South Pickett Street 

Alexandria, VA 22304-4605 

Attn.: LOMC Manager 

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. 

 

Please make check or money order payable to the National Flood Insurance Program. 

 

Type of Request: 

 MT-1 application 

 MT-2 application 

 

 

 

 

 

 EDR application 

 

 

 

Request No. (if known): _______________ Check No.: _______________ 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 


 

 

 

 

— 

 

 

 

 

— 

 

 

 

 

— 

 

 

 

 

 

 

 

— 

 

 

 



 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Month Year 

 

 

 _________________________________________________________________ 

Date Signature 

 

NAME (AS IT APPEARS ON CARD): 

(please print or type) 

 

ADDRESS: 

(for your 

credit card 
receipt-please 
print or type) 

 

DAYTIME PHONE: