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State of West Virginia Department of Military Affairs and Public Safety Sterling Lewis, Jr. State Fire Marshal Earl Ray Tomblin, Governor Phone: (304) 558-2191 Fax: (304) 558-2537 STATE FIRE MARSHAL’S OFFICE nd 1207 Quarrier St, 2 Floor Charleston, WV 25301 Year 2011 Certification and Disbursement Application For State Funds Insurance Premium Tax Money (Return this application to this office no later than January 31, 2011) ALL 2010 NFIRS REPORTS MUST BE SUBMITTED TO RECEIVE FUNDS I. Fire Department Data: (All fields are required – Complete front and back) PLEASE PRINT! Department Name: FDID Number: Mailing Address: City: Dept. Physical Address: Dept. Email Address: Department Phone: Dept. Fax: Department Type: Volunteer Part-Paid FEIN TAX NUMBER: Do All Fire Dept Vehicles Have An Emergency Vehicle Permit? Yes Do All Applicable Private Vehicles Have An Emergency Vehicle Permit? Yes Substations? Yes ISO Rating: County: Zip: No No How Many? ___ Chief's Name: Chief's Work Phone: Chief’s Home Address: Chief's Email Address: Chief's Home Phone: Chief's Cell Phone: City: Ass’t Chief’s Name: Ass’t Chief's Home Phone: 8am-4pm Contact Person: Contact Person's Phone: NFIRS Reporting Officer: NFIRS Rpt Officer's Email: NFIRS Rpt Officer's Phone: NFIRS Rpt Officer's Alternate Email: State: No Zip: II. Training: § 8-15-8a “Each volunteer or part volunteer fire company or department must: (b) Complete or be in the process of receiving firefighter training, including Section One of the West Virginia University Fire Service Extension or its equivalent. Such fire company or department must have at least ten members certified having completed such training or if a volunteer fire company or department has twenty or fewer members, fifty percent of the active volunteer members must have completed such training.” Total Number of ACTIVE Members: _____ Total Number of ACTIVE Members with Fire Fighter 1 (Level 1): _____ III. Fire Reporting: § 8-15-8a “Each volunteer or part volunteer fire company or department must: (a) Submit and maintain current submission of fire loss data to the State Fire Marshal, including verification, by notarized statement, if no fire loss has occurred.” To obtain more information about NFIRS 5.0, visit the website at www.nfirs.fema.gov, or contact the SFMO Public Education Division at (304) 558-2191, Ext. 53223. IV. Statement: I, _________________________________________, herewith certify that as of_______________I have been duly (Printed Name of Chief) (Appointed / Elected Date) appointed or elected as the Chief of this department and that this fire department or fire company complies with all Federal and State laws to the best of my knowledge. I am aware that by neglecting to submit any and all fire reports and non-fire activity reports in a timely manner, my department may not be certified to receive state funding. All required information contained in this application is complete, true and accurate. Date: ______________ Fire Chief’s Signature: _______________________________________ Return this application to: WV State Fire Marshal’s Office Public Education Division nd 1207 Quarrier St., 2 Floor Charleston, WV 25301 No later than January 31, 2011 All forms and applications are now available online. Please visit our web site to expedite your needs and requests at: www.firemarshal.wv.gov. Office personnel can also be contacted via E-mail at the website. Important Notice--USFA Assistance to Firefighters’ Grants The SFMO is working closely with FEMA to ensure FD compliance with grant funding requirements as they concern NFIRS. FEMA will be automatically notified each quarter of departments that are delinquent in submitting their incident reports. If your department fails to report consistently, including for the 12 month period after your USFA grant award begins, FEMA has assured us your department will be unable to close out your grant funding at the end of your award year. In extreme cases of reporting negligence, FEMA can take steps to freeze grant monies until such time as compliance is verified by this office.