Missouri Advisory Committee on Arson Prevention
www.macap.org
Missouri Arson Award Nomination

c/o NCCI
PO Box 18416
Kansas City, MO 64133

Nominator:        
Name:
     
Department:
Title:
 
Phone Number:
Email:
required field
Street Address:
              
City:
State:   Zip:  
        

Fire Loss:      
Address of Fire: Date of Fire:
/ / mm/dd/yyyy
Insurance Company:    
 
Insurance Company Contact: Contact Phone:
Insurance Company Address:  
 
Estimated Amount of Loss:    

 

 
Name of Accused:
Date of Arrest/Conviction:
Legal jurisdiction/sentence/disposition/remarks -
 
    

Nominee:      
Name:
Phone Number:
     
Address:
Age:
        

Special Information:
Did the nominee volunteer this information?    
Was the nominee involved in this crime as a participant?    
Did the nominee agree to testify?    
Did the nominee testify?
If Yes:
Grand Jury
Preliminary Hearings
Trial
Was the nominee's life placed in jeopardy?    
If so, how?      

       
Was the nominee willing to assist in the investigation?
   
If so, how?
     
Gave statement
   
Involved in undercover contact
   
Taped conversation(s)
   
Produced physical evidence
   

Other assistance

   
If yes, explain
       
Did the nominee's information and/or assistance result in:      
Denial of fraud claim    
Arrest and/or indictment    
Identification of additional suspects    
Confessions    
Were any hardships placed on the nominee as a result of coming forward with information?    
If yes, explain briefly
       
Did the nominee come forward as a result of involvement in any plea bargain arrangement related to:      
This crime act    
Unrelated criminal acts committed by nominee    
If yes, briefly explain agreement:
       
       
Narrative Comments:      
I think should be considered for the Arson Alert Committee's Arson Award because of the following.

       
Please send any reports, news articles, or other documents pertinent to nominee's information to assist review committee.