Fire Start Date: Fire Start Time: IC S Name

STATE OF NEW MEXICO Fire Number Energy, Minerals and Natural Resources Department Forestry Division Fire Name FIRE DEPARTMENT REIMBURSEMENT REQUEST Fire Department

INCIDENT DETAILS:

Fire Start Date: Fire Start Time: IC’s Name:

County:

Ownership:

Forest Cover Type:

Fuel Type– (what actually burned):

General Cause: Other

Structures Threatened Number and Type:

Number of Structures Burned:

Fire Location: T. R. Section 1/4Section

and/or Latitude Longitude

Acreage Burned by Land Ownership: (number of acres in blanks)

BIA BLM FWS NPS Private State USFS Other (specify)

Dispatch: Date Time Acres

Initial Attack: Date Time Acres

Controlled: Date Time Acres

Back To Station: Date Time Acres

Slope at Origin:

Aspect at Origin:

Temperature: (°F) RH: % Wind Speed: Wind Direction:

Fire Behavior on Initial Attack:

FORM COMPLETED BY TITLE DATE STATE OF NEW MEXICO FIRE NUMBER: Energy, Minerals and Natural Resources Department Forestry Division

FIRE DEPARTMENT FIRE NAME: REIMBURSEMENT REQUEST

Equipment Equipment Description License Number # of Hours *Rate per Hour Total 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 10 0 11 0 12 0

Total Reimbursement 0 Make Reimbursement Payable to: Name: CITY OF CLOVIS FOR CLOVIS FIRE DEPARTMENT

Address: P.O. BOX 760 Vendor No.:0000054320

City: CLOVIS State: NM Zip Code: 88102

*Use current equipment rate schedule DIVISION **Checks are made payable to the governing APPROVAL  body or fiscal agent of fire department. District Forester Date CERTIFICATION FIRE DEPARTMENT (Chief) Date I certify that the above services were rendered as stated: that they were necessary and proper, that the amounts claimed are just and reasonable FISCAL AGENT FOR FIRE DEPARTMENT Date and that no part thereof has been paid.