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r <br /> FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> PAYMENT INFORMATION FORM <br /> ommunity Name: City of Eugene, OR Community No. 410122 <br /> Project Identifier: Eugene Delta Ponds <br /> THIS FORM MUST BE MAILED, ALONG WITH THE APPROPRIATE FEE, TO ONE OF TWO POST OFFICE BOXES (SEE BELOW) OR FAXED TO <br /> THE FAX NUMBER BELOW. <br /> Type of Request: <br /> MT-1 application fee ~ {Insert 3173 as the P.O. Box number in the address below) <br /> MT-2 application fee. <br /> External Data Requests (EDRs) (Insert 398 as the P.O. Box number in the address below) <br /> Federal Emergency Management Agency <br /> Revisions Fee-Collection System Administrator <br /> P.O. Box 2278 <br /> Merrifield, Virginia 22116 <br /> Fax: (703)849-0282 <br /> Request No.: Case 05-10-0273R (if known) Amount: $4,000 <br /> ® INITIAL FEE* ? FINAL FEE ? FEE BALANCE** ? MASTER CARD ? VISA ? CHECK ? MONEY ORDER <br /> *Npte: 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 /> OtiMPLETE THIS SECTION ONLY IF PAYING BY CREDIT CARD <br /> EXP. DATE <br /> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Month Year <br /> CARD HUMBER <br /> Date Signature <br /> NAME (AS IT APPEARS ON CARD): <br /> (please print or type) <br /> ADDRESS: Z~ U ~ ~ ~ ~ ^7 ~ ~ j <br /> (for your <br /> credit card <br /> receipt-please <br /> <br /> print or type) ~TE <br /> DAYTIME PHONE: ~~~I~1~ <br /> FEMA Form 81-107, Payment Information Form <br /> <br />