Fema Form 086-0-27 - Overview & Concurrence Form - 2011-2014 (Page 2 of 3) in pdf

The area of revision encompasses the following structures (check all that apply)

Structures:

Channelization

Levee/Floodwall

Bridge/Culvert

Dam

Fill

Other (Attach Description)

Documentation of ESA compliance is submitted (required to initiate CLOMR review). Please refer to the instructions for more information.

C. REVIEW FEE

Has the review fee for the appropriate request category been included?

Yes

Fee amount: $

No, Attach Explanation

Please see the DHS-FEMA Web site at

for Fee Amounts and Exemptions.

D. SIGNATURE

All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable by

fine or imprisonment under Title 18 of the United States Code, Section 1001.

Name:

Company:

Mailing Address:

Daytime Telephone No.:

Fax No.:

E-Mail Address:

Signature of Requester (required):

Date:

As the community official responsible for floodplain management, I hereby acknowledge that we have received and reviewed this Letter of Map Revision

(LOMR) or conditional LOMR 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 requirements for when fill is placed in the regulatory floodway, and that all

For Conditional LOMR requests, the

necessary Federal, State, and local permits have been, or in the case of a conditional LOMR, will be obtained.

applicant has documented Endangered Species Act (ESA) compliance to FEMA prior to FEMA’s review of the Conditional LOMR application. For

LOMR requests, I acknowledge that compliance with Sections 9 and 10 of the ESA has been achieved independently of FEMA’s process. 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.

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 FEMA, all analyses and

documentation used to make this determination.

Community Official’s Name and Title:

Community Name:

Mailing Address:

Daytime Telephone No.:

Fax No.:

E-Mail Address:

Community Official’s Signature (required):

Date:

CERTIFICATION BY REGISTERED PROFESSIONAL ENGINEER AND/OR LAND SURVEYOR

This certification is to be signed and sealed by a licensed land surveyor, registered professional engineer, or architect authorized by law to certify

elevation information data, hydrologic and hydraulic analysis, and any other supporting information as per NFIP regulations paragraph 65.2(b) and as

described in the MT-2 Forms Instructions. All documents submitted in support of this request are correct to the best of my knowledge. I understand that

any false statement may be punishable by fine or imprisonment under Title 18 of the United States Code, Section 1001.

Certifier’s Name:

License No.:

Expiration Date:

Company Name:

Telephone No.:

Fax No.:

Signature:

Date:

E-Mail Address:

FEMA Form 086-0-27, (2/2011)

Previously FEMA Form 81-89