Forms • Merced County, CA • CivicEngage

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Fire Department Impairment Notification

Leave This Blank:

Impairment Address or Parcel Number
Assessor's Parcel Number (APN) of the property with impairment:
Street Address	City	Zip

Please provide a description of the impairment and expected duration (Be as specific and complete as possible):
If known, please provide the name of the responsible person(i.e. tenant, property owner, etc.):
Please provide a description of the impairment (Be as specific and complete as possible):

The following fields are required:
Prefix:
First Name:*
Last Name:*

Your Address
Street Address*	City*	Zip*

Phone Number: *
Email Address:
Cell Phone:

* indicates required fields.

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