2. 
3. Kinston Department of Fire and Rescue
   P. O. Drawer 339, 401 E Vernon Avenue Kinston, North Carolina 28502 Office Phone: 252-939-3164 Fax Phone : 252-939-3157
5. Fire Incident Report Request Form
7. Requester Information
8. Date of Request*
   Date of Request
10. Name of Requester:*
11. Middle Name:
12. Last Name:*
14. Address:*
16. City:*
17. State:*
18. Zip Code:*
20. Contact Phone Number:*
21. Email Address:*
23. Incident Information
25. Date of Incident (If Known):
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
26. Day:
    -- Select One --01020304050607080910111213141516171819202122232425262728293031
27. Year:
    -- Select One --201720182019202020212022202320242025202620272028202920302031203220332034203520362037
29. Address of Incident:*
31. City:
32. State:
33. Zip Code:
35. Name of Owner (If Not Requester):
37. Middle Name (if known):
39. Last Name:
41. Name of Occupant/Renter of the Property (If not the Requester):
43. Middle Name (if known):
45. Last Name:
47. Is the Property Insured:*

    1. Yes

    1. No

    1. Unknown
49. If Yes please list the name of the Insurance Company/Group:
51. Number of Copies Requested:

    1. Owner's Copy
    2. Renter's Copy

    1. Insurance Company Adjuster's Copy
    2. Private Fire Investigator's Copy
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field