2020/06/08 - OTHER - (NA) - Notice

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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: ❑■ Copy of the effective FIRM panel on which the structure and/or property location has been accurately plotted(property inadvertently located in the NFIP regulatory floodway will require Section B of MT-1 Form 3) ❑■ Copy of the Subdivision Plat Map for the property(with recordation data and stamp of the Recorder's Office) OR ❑ 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 showing the surveyed location of the property relative to local streets and watercourses. The map should include at least one street intersection that is shown on the FIRM panel. • E 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 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 provided on Form 2. ■❑ Please include a map scale and North arrow on all maps submitted. For LOMR-Fs and CLOMR-Fs,the following must be submitted in addition to the items listed above: ❑■ Form 3—Community Acknowledgment Form For CLOMR-Fs,the following must be submitted in addition to the items listed above: ❑Documented ESA compliance,which may include a copy of an Incidental Take Permit,an Incidental Take Statement,a"not likely to adversely affect" 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 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 information. Please do not submit original documents. Please retain a copy of all submitted documents for your records. DHS-FEMA encourages the submission of all required data in a digital format(e.g.scanned documents and images on Compact Disc[CD]). Digital submissions help to further DHS-FEMA's Digital Vision and also may facilitate the processing of your request. Incomplete submissions will result in processing delays.For additional information regarding this form,including where to obtain the supporting documents listed above,please refer to the MT-1 Form Instructions located at http://www.fema.gov/plan/prevent/fhm/dl_mt-l.shtm. Processing Fee(see instructions for appropriate mailing address;or visit http://www.fema.gov/fhm/frm_fees.shtm for the most current fee schedule) Revised fee schedules are published periodically,but no more than once annually,as noted in the Federal Register. Please note: single/multiple lot(s)/structure(s)LOMAs are fee exempt. The current review and processing fees are listed below: Check the fee that applies to your request: ❑$325(single lot/structure LOMR-F following a CLOMR-F) ❑■ $425(single lot/structure LOMR-F) ❑$500(single lot/structure CLOMA or CLOMR-F) ❑$700(multiple lot/structure LOMR-F following a CLOMR-F,or multiple lot/structure CLOMA) ❑$800(multiple lot/structure LOMR-F or CLOMR-F) Please submit the Payment Information Form for remittance of applicable fees. Please make your check or money order payable to: National Flood Insurance Program. 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. Applicant's Name(required): Mark E. Krause Company(if applicable): Wagner Surveying Associates, Inc. Mailing Address(required): Daytime Telephone No.(required): (71 5)866-4295 P.O. Box#89,Webster, WI, 54893 E-Mail Address(optional):❑■ By checking here you may receive Fax No.(optional): (715)866-4206 correspondence electronically at the email address provided): 044. E. 910.044 Date(required) 06/08/2020 Signature of Applicant(required) DHS-FEMA Form 086-0-26,FEB 11 Property Information Form MT-1 Form 1 Page 2 of 2