FEDERAL EMERGENCY MANAGEMENT AGENCY
PAYMENT INFORMATION FORM
:Community Name
Project Identifier:
MT-1 application
T-2 application
Type of Request:
THIS FORM MUST BE MAILED, ALONG WITH THE APPROPRIATE FEE, TO THE ADDRESS BELOW OR E-MAILED TO THE E-MAIL
ADDRESS BELOW.
Please make check or money order payable to the National Flood Insurance Program.
E
): _______________
Check No.:
____ _________ __
Amou nt:
INITIAL FEE FINAL FEE FEE BALANCE** MASTER CARD VISA MONEY ORDER
— — —
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Month
_________________________________________________________________
:
M
Request No. (if known
* CHECK
*Note: Check only for EDR and/or Alluvial Fan requests (as appropriate).
**Note: Check only if submitting a corrected fee for an ongoing request.
DR application
LOMC Clearinghouse
3601 Eisenhower Ave. Suite 500 Alexandria, VA
22304-6426
Attn.: LOMC Manager
FEMA Project Library
3601 Eisenhower Ave. Suite 500 Alexandria, VA
22304-6426
E-mail: [email protected]
COMPLETE THIS SECTION ONLY IF PAYING BY CREDIT CARD
CARD NUMBER EXP. DATE
—
Year
Date Signature
NAME (AS IT APPEARS ON CARD)
(please print or type)
ADDRESS:
(for your
credit card
receipt-please
print or type)
DAYTIME PHONE:
FEMA Form 81-107 Payment Informa
tion Form
