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Note A 20 charge will be assessed for all returned checks If you checked box 1 on the Self-Inspection Form and elected not to participate in the Self-Inspection Program You must fully complete box 1 and 12 on the Self Inspection Form and return the SelfInspection Form postmarked no later than April 5 2013 Deadline to o Indianapolis Fire Department 300 Fall Creek Pkwy N. Dr. INDIANAPOLIS FIRE DEPARTMENT Fire Life Safety Division Chief Fred Pervine Fire Marshal PAYMENT INSTRUCTIONS After completing the Self-Inspection Form Self- Inspection Fee 25 Mail fully completed Self Inspection Form and check made payable to o City of Indianapolis Office of Finance and Management 200 E Washington St Room 2260 Indianapolis Indiana 46204 Credit Card/Debit Card payments are accepted by phone at 317 327-4181. Additional fees will apply o The fully completed Self Inspection Form must be received within 7 days of paying by phone to avoid the possibility of additional fees. Suite 500 Indianapolis IN 46205 DO NOT SEND A PAYMENT AT THIS TIME* You will be billed an inspection fee at the time of your fire safety inspection which will be based upon the square footage of your structure. See IFD Inspection Fee Chart below If you fail to respond by the Deadline listed above You will be ineligible to participate in the Self-Inspection Program for this current inspection year. Your property/structure will be inspected by IFD and you will be charged a fee based upon the IFD Inspection Fee Chart listed below. You will also be subject to a collection fee 20 of the Inspection Fee o 1 3 000 sq. feet o 3 001 10 000 sq. feet 50. 00 100. 00 ADDITIONAL FEES All structures that have fire safety law violations that are not promptly remedied within 30 days from completion of the Self Inspection Form will be subject to an additional reinspection fee of 80 for each subsequent inspection required to verify such violation s has been appropriately remedied* NO FORMS OF PAYMENT WILL BE ACCEPTED BY THE INSPECTOR s. ALL PAYMENTS MUST BE MADE TO THE CITY OF INDIANAPOLIS AS DIRECTED ON THIS PAYMENT INSTRUCTION FORM. Suite 500 Indianapolis IN 46205 DO NOT SEND A PAYMENT AT THIS TIME* You will be billed an inspection fee at the time of your fire safety inspection which will be based upon the square footage of your structure. See IFD Inspection Fee Chart below If you fail to respond by the Deadline listed above You will be ineligible to participate in the Self-Inspection Program for this current inspection year. See IFD Inspection Fee Chart below If you fail to respond by the Deadline listed above You will be ineligible to participate in the Self-Inspection Program for this current inspection year. Your property/structure will be inspected by IFD and you will be charged a fee based upon the IFD Inspection Fee Chart listed below. Your property/structure will be inspected by IFD and you will be charged a fee based upon the IFD Inspection Fee Chart listed below. You will also be subject to a collection fee 20 of the Inspection Fee o 1 3 000 sq. feet o 3 001 10 000 sq.

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