2. Open Records Information

   This form is to request an incident report filed by the Marietta Fire Department.  Open records requests related to environmental studies, historical building or site information, etc., must be submitted through the City Clerk's Office by visiting https://www.mariettaga.gov/569/City-Clerk.

4. Preferred Method of Delivery?*

   1. E-Mail
   2. Fax
   3. Regular Mail
   4. Walk-In
5. Date of Request*
   Date of Request
6. Time*
   Time
10. Requestor Information
12. First Name*
13. Last Name*
15. Company/Organization
17. Address *
19. City*
20. State*
21. Zip*
23. Phone Number*
24. Fax Number if Applicable
26. Email Address*
30. Incident Information for Report

    Fire Incident Reports are subject to open records; however, an emergency medical service record/report will require the patient, legal guardian, or power of attorney to provide photo identification. When a person other than the patient requests an emergency medical record/report, a notarized HIPAA authorization form or court order is required. Copies of emergency medical records/reports must be picked up in person.

32. Type of Incident*
    -- Select One --Building FireVehicle FireFire - OtherEmergency Medical Services (EMS)Motor Vehicle CollisionWeather Related EmergencyOther
34. Address of Incident*
36. City
37. State
38. Zip Code
40. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
41. Marietta Fire Incident/Case Number
43. Any Additional Details for Request
45. Government issued photo ID (when required)
46. Authorization Document (when required)
50. Signature of person making the request*
    The City will respond to this request within five (5) working days.
52. Do you agree?*

    By clicking "I agree," you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I Agree
Leave This Blank:


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

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field