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3x ry.- #3q6 DEPARTMENT OF HOMELAND SECURITY-FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.NO.1660-0015 PROPERTY INFORMATION FORM Expires February 28,2014 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 1.63 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,gathering and maintaining the needed data,and completing and submitting the form. This collection is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to:Information Collections Management,Department of Homeland Security,Federal Emergency Management Agency,1800 South Bell Street,Arlington,VA 20598-3005,Paperwork Reduction Project(1660-0015). NOTE:Do not send your completed form to this address. This form may be completed by the property owner,property owner's agent,licensed land surveyor,or registered professional engineer to support a request for a Letter of Map Amendment(LOMA),Conditional Letter of Map Amendment(CLOMA),Letter of Map Revision Based on Fill(LOMR-F),or Conditional Letter of Map Revision Based on Fill(CLOMR-F)for existing or proposed,single or multiple lots/structures. In order to process your request,all information on this form must be completed in its entirety,unless stated as optional. Incomplete submissions will result in processing delays. Please check the item below that describes your request: ❑ LOMA A letter from DHS-FEMA stating that an existing structure or parcel of land that has not been elevated by fill(natural grade)would not be inundated by the base flood. ❑ CLOMA A letter from DHS-FEMA stating that a proposed structure that is not to be elevated by fill(natural grade)would not be inundated by the base flood if built as proposed. ® LOM R-F A letter from DHS-FEMA stating that an existing structure or parcel of land that has been elevated by fill would not be inundated by the base flood. A letter from DHS-FEMA stating that a parcel of land or proposed structure that will be elevated by fill ❑ CLOM R-F would not be inundated by the base flood if fill is placed on the parcel as proposed or the structure is built as proposed. Fill is defined as material from any source(including the subject property)placed that raises the ground to or above the Base Flood Elevation(BFE). The common construction practice of removing unsuitable existing material(topsoil)and backfilling with select structural material is not considered the placement of fill if the practice does not alter the existing(natural grade)elevation,which is at or above the BFE. Fill that is placed before the date of the first National Flood Insurance Program(NFIP)map showing the area in a Special Flood Hazard Area(SFHA)is considered natural grade. Has fill been placed on your property to raise 03/2008 ground that was previously below the BFE? ® Yes ❑ No If yes,when was fill placed? mm/dd/yyyy Will fill be placed on your property to raise ground that is below the BFE? ❑ Yes* ® No If yes,when will fill be placed? mm/dd/yyyy *If yes,Endangered Species Act(ESA)compliance must be documented to FEMA prior to issuance of the CLOMR-F determination(please refer page 4 to the MT-1 instructions). 1. Street Address of the Property(if request is for multiple structures or units,please attach additional sheet referencing each address and enter street names below): 7504 Lagoon Lane, Webster, WI 54893 2. Legal description of Property(Lot,Block,Subdivision or abbreviated description from the Deed): Big Yellow Lake Estates Lot 4, Sec 29 T40N R16W, Oakland Township, Burnett County, WI 3. Are you requesting that a flood zone determination be completed for(check one): N Structures on the property? What are the dates of construction? 07/2008 (MM/YYYY) ❑ A portion of land within the bounds of the property?(A certified metes and bounds description and map of the area to be removed,certified by a licensed land surveyor or registered professional engineer,are required.For the preferred format of metes and bounds descriptions,please refer to the MT-1 Form 1 Instructions.) ❑ The entire legally recorded property? 4. Is this request for a(check one): I) Single structure ❑ Single lot ❑ Multiple structures(How many structures are involved in your request?List the number: ) ❑ Multiple lots(How many lots are involved in your request?List the number: ) DHS-FEMA Form 086-0-26,FEB 11 Property Information Form MT-1 Form 1 Page 1 of 2