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FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> PAYMENT INFORMATION FORM <br /> Community Name: <br /> Project Identifier: <br /> THIS FORM MUST BE MAILED,ALONG WITH THE APPROPRIATE FEE,TO THE ADDRESS BELOW OR FAXED TO THE FAX NUMBER <br /> BELOW. <br /> Please make check or money order payable to the National Flood Insurance Program. <br /> Type of Request: LOMC Clearinghouse <br /> ❑ MT-1 application 847 South Pickett Street <br /> ❑ MT-2 application Alexandria,VA 22304-4605 <br /> Attn.: LOMC Manager <br /> FEMA Project Library <br /> ❑ EDR application 847 South Pickett Street <br /> Alexandria,VA 22304-4605 <br /> FAX(703)212-4090 <br /> Request No.(if known): Check No.: Amount: <br /> ❑ INITIAL FEE* ❑ FINAL FEE ❑ FEE BALANCE" ❑ MASTERCARD ❑ VISA ❑ CHECK ❑ MONEY ORDER <br /> *Note: Check only for EDR and/or Alluvial Fan requests(as appropriate). <br /> **Note:Check only if submitting a corrected fee for an ongoing request. <br /> COMPLETE THIS SECTION ONLY IF PAYING BY CREDIT CARD <br /> CARD NUMBER EXP. DATE <br /> F - 71 1 1 - 1 1 1 1 1 - 1 1 1 1 � <br /> m m <br /> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Month Year <br /> Date Signature <br /> NAME (AS ITAPPEARS ON CARD): <br /> (please print or type) <br /> ADDRESS: <br /> (for your <br /> credit card <br /> receipt-please <br /> print or type) <br /> DAYTIME PHONE: <br /> FEMA Form 81-107 Payment Information Form <br />