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2. Full address of Property*
4. Date of Fire/Explosion
   Date of Fire/Explosion

   Date of Fire/Explosion
6. JHF/EMS Case #
8. First Name*
9. Last Name*
11. Agency Requesting Report*
13. Description of Requested Information*
15. Mailing Address*
17. Phone Number*
19. Email*
21. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Electronic Signature
25. Select One
    -- Select One --Fire DepartmentLaw Enforcement entity of Wyoming or U.S. GovernmentCounty, District, or U.S. AttorneyParty in Civil Litigation with legitimate interest in propertyInsurance Company with legitimate interest in propertyProperty Owner or DesigneeMedia
27. Records Requested
    -- Select One --Investigation Summary ReportFull Investigation ReportPhotos
29. Requested Method of Return
    -- Select One --USPSEmailIn Person (pick up)
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field