| Date of fire:
Time of fire:
Case number: |
| Address of fire:
City:
County: |
| Victim’s
insurance company: _____________________________ Amount of Loss: ___________ (and contact person)
______________________________________________________________ |
| Type of fire: ___ Structure____Vehicle____Outdoor____Other |
#
fatalities:_________ # Deaths:___________ |
| Investigator’s
synopsis of case: ( Intent? Risk to firefighter? Community impact?)
(Add additional pages if necessary) |
| Investigator’s
comments regarding informant: (Motive? Relationship to case?
Personal Safety?) |
| Reward
recipient’s name:(optional)__________________ How did
recipient of reward find out about the reward program? |
Amount
Recommended:$ __________________ |
| Submitted by:
_______________________________________ Date: __________________ Department / Organization:
____________________________________________________
Address: __________________________________ City: ___________________
Zip: _____ |
| (MNIAAI USE ONLY) |
| Disposition Yes: ___ No: ____ |
Committe members voting: |
| Amount Paid:$_____________ |
| Date: ____________ CK:_____ |
| Award Paid To:__ __________ |
