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In addition to this form(MT-1 Form 1),please complete the checklist below. ALL requests must include one copy of the following: <br /> ® Copy of the effective FIRM panel on which the structure and/or property location has been accurately plotted(property inadvertently located in the NFIP <br /> regulatory floodway will require Section B of MT-1 Form 3) <br /> ® Copy of the Subdivision Plat Map for the property(with recordation data and stamp of the Recorder's Office) <br /> OR <br /> ❑ Copy of the Property Deed(with recordation data and stamp of the Recorder's Office),accompanied by a tax assessor's map or other certified map <br /> showing the surveyed location of the property relative to local streets and watercourses. The map should include at least one street intersection that is <br /> shown on the FIRM panel. <br /> ® Form 2—Elevation Form. If the request is to remove the structure,and an Elevation Certificate has already been completed for this property,it may be <br /> submitted in lieu of Form 2. If the request is to remove the entire legally recorded property,or a portion thereof,the lowest lot elevation must be <br /> provided on Form 2. <br /> ® Please include a map scale and North arrow on all maps submitted. <br /> For LOMR-Fs and CLOMR-Fs,the following must be submitted in addition to the items listed above: <br /> ® Form 3—community Acknowledgment Form <br /> For CLOMR-Fs,the following must be submitted in addition to the items listed above: <br /> ❑Documented ESA compliance,which may include a copy of an Incidental Take Permit,an Incidental Take Statement,a"not likely to adversely affect" <br /> determination from the National Marine Fisheries Service(NMFS)or the U.S.Fish and Wildlife Service(USFWS),or an official letter from NMFS or USFWS <br /> concurring that the project has"No Effect"on proposed or listed species or designated critical habitat.Please refer to the MT-1 instructions for additional <br /> information. <br /> Please do not submit original documents. Please retain a copy of all submitted documents for your records. <br /> DHS-FEMA encourages the submission of all required data in a digital format(e.g.scanned documents and images on Compact Disc[CD]). Digital <br /> submissions help to further DHS-FEMA's Digital Vision and also may facilitate the processing of your request. <br /> Incomplete submissions will result in processing delays.For additional information regarding this form,including where to obtain the supporting <br /> documents listed above,please refer to the MT-1 Form Instructions located at http://www.fema.gov/plan/prevent/fhm/dl_mt-i.shtm. <br /> Processing Fee(see instructions for appropriate mailing address;or visit http://www.fema.gov/fhm/frm_fees.shtm for the most current fee <br /> schedule) <br /> Revised fee schedules are published periodically,but no more than once annually,as noted in the Federal Register. Please note: single/multiple <br /> lot(s)/structure(s)LOMAs are fee exempt. The current review and processing fees are listed below: <br /> Check the fee that applies to your request: <br /> ❑$325(single lot/structure LOMR-F following a CLOMR-F) <br /> ®$425(single lot/structure LOMR-F) <br /> ❑$SOD(single lot/structure CLOMA or CLOMR-F) <br /> ❑$700(multiple lot/structure LOMR-F following a CLOMR-F,or multiple lot/structure CLOMA) <br /> ❑$800(multiple lot/structure LOMR-F or CLOMR-F) <br /> Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to: <br /> National Flood Insurance Program. <br /> 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 <br /> or imprisonment under Title 18 of the United States Code,Section 1001. ` <br /> Applicant's Name(required): MARK E. KIZAPtE Company(if applicable): 1AAd&wC_P ,S�rvPy�nb ASSOc,Tft <br /> Mailing Address(required): PC Sox i q Daytime Telephone No.(required): 7/s 46 Vn_4Z175 <br /> wilsitr W, f494% <br /> E-Mail Address(optional):❑By checking here you may receive Fax No.(optional): <br /> correspondence electronically at the email address provided): <br /> walrick svii wt op CemYvryiel•hell /V <br /> Date(required) I f// /r� <br /> %,I <br /> //// / r Signature of Applicant(required) <br /> DHS-FEMA Form 086-0-26,FEB 11 Property Information Form MT-1 Form 1 Page 2 of 2 <br />