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2. Name*
3. Email Address*
5. Address of Incident*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
13. Are You the Occupant or Owner*

    1. Yes
    2. No
15. Involvement*

    If you are not the owner, please state the reason for the request:

    
    

17. Fire Incident Location/Address*
19. Date/Time for Requested Incident*
    Date/Time for Requested Incident

    Date/Time for Requested Incident
20. Open Records Request

    If you are submitting an Open Records Request in accordance with the Georgia Law, please submit your request on agency/department letter head.

22. Type of Incident*

    1. Structure Fire
    2. Vehicle Fire
    3. Auto Accident
    4. Medical Incident
    5. Other

    
    

    
    

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field