STATE OF NEW MEXICO
Energy, Minerals and Natural Resources Department
Forestry Division
FIRE DEPARTMENT
REIMBURSEMENT REQUEST / Fire Number
Fire Name
Fire Department
INCIDENT DETAILS:
Fire Start Date: Fire Start Time: IC’s Name:
County:
Ownership: PrivateStateFederalOther PublicUnknown

Forest Cover Type:

Fuel Type– (what actually burned):

General Cause: Other

Structures Threatened Number and Type:

Number of Structures Burned:

Fire Location: T.R.Section1/4Section

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: 0-00-2526-4041-5556-7576-200

Aspect at Origin:

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

Fire Behavior on Initial Attack:

FORM COMPLETED BY TITLE DATE
/
STATE OF NEW MEXICO
Energy, Minerals and Natural Resources Department
Forestry Division
FIRE DEPARTMENT
REIMBURSEMENT REQUEST
/ FIRE NUMBER:
FIRE NAME:
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
Make Reimbursement Payable to: / Total Reimbursement / 0
Name: RIO ARRIBA COUNTY
for
Address: 1122 INDUSTRIAL PARK ROAD / Vendor No.: 0000045766
City: ESPANOLA / State: NM / Zip Code: 87532
*Use current equipment rate schedule
**Checks are made payable to the governing
body or fiscal agent of fire department. / DIVISION APPROVAL / ü 
District Forester Date

CERTIFICATION

I certify that the above services were rendered as stated: that they were necessary and proper, that the amounts claimed are just and reasonable and that no part thereof has been paid. /
FIRE DEPARTMENT (Chief) Date
FISCAL AGENT FOR FIRE DEPARTMENT Date