SHELBINA FIRE PROTECTION DISTRICT

HOME SMOKE DETECTOR PROGRAM

This program is designed to assist families and senior citizens over the age of 55 with household incomes of less than $25,000 that are in need of smoke detectors in their homes. Smoke detectors will be installed or checked free of charge to qualifying residents of Shelbina Fire Protection District as supplies permit. The Shelbina Fire Protection District will distribute detectors to homes based on the criteria given below.

• By signing below you are requesting Shelbina Fire Protection District personnel to enter your home and provide an evaluation of your current smoke detectors and install additional smoke detectors as deemed necessary.
• By signing below, recipient agrees to read and follow the smoke detector instructions found in the owner’s manual at all times.
• By signing below, recipient and anyone acting on his/her behalf knowingly and willingly agrees to fully release, hold harmless, defend, and indemnify Shelbina Fire Protection District, its directors, officers, employees, agents, successors, and affiliates from all costs, claims, liabilities which in any way may be related to recipient’s referral, acquisition, and use of the smoke detector(s) provided to him/her as part of this offer.

Name _______________________________________________________ Date _____________________

Address ____________________________________________ City/Zip ___________________________

Phone # ______________________________________ Best time to call ___________________ AM PM

Is your home located within the boundaries of the Shelbina Fire Protection District? Y N

Age of residents in the home Oldest _______ Youngest ______ Total number of residents ________

Number of detectors currently in the home _________ Is there a working detector on each floor? Y N

What is your annual household income? Less than $15,000 $15,000-$24,999 Over $25,000

Do you own or rent your home? Own Rent (If rental, signature of landlord is required)

Signature of landlord (if rental) ________________________________________________

I attest to the validity of the information provided above. I understand that I may be asked to provide verification of any information provided.

Signature of resident ________________________________________________________

**************** THIS SECTION COMPLETED UPON INSTALLATION OF DETECTOR(S) *****************

I, the homeowner/renter of the home at the above address understand the information I have been given and agree to keep smoke detectors in working order. If unable to do so, I will notify the Shelbina Fire Protection District for assistance.

Signature of resident ________________________________________________________

************************* FIRE DISTRICT USE ONLY BELOW THIS LINE ****************************

Names of installers ____________________________________________________________________

# of smoke detectors checked _______ # of smoke detectors installed ______ Date installed __________________

# of batteries installed ______________ Is a working smoke detector on every level of the home? Y N

Comments: ___________________________________________________________________________________