New Jersey Administrative Code, Chapter 88, Appendix - APPENDIX | New Jersey Administrative Code

APPLICANT INFORMATION

Name: ___________________________________________________________________

Address: ___________________________________________________________________

Number and Street Apt. No.

___________________________________________________________________

City State Zip Code

Phone: (H) __________________________ (W) __________________________

Email: _______________________________

Do you wish to keep your identity confidential? Yes ________ No ________

Nondisclosure of your identity is subject to any statute, Rule of Court or

judicial decision which may require divulgence of such identity to certain

parties including, in certain circumstances, criminal defendants.

DEADLINE: A reward application must be filed within 30 days of the date on

which the applicant initially provided the information to OIFP.

INFORMATION PROVIDED

(You may attach additional sheets if needed)

Date(s) of Incident: _______________________________________________________

Location: __________________________________________________________________

Detailed Description of Incident: __________________________________________

_____________________________________________________________________________

Suspect(s): Name _________________________________________________

Address _________________________________________________

_________________________________________________

Witness(es): Name _________________________________________________

Address _________________________________________________

I hereby certify that the information provided above is true and accurate.

I am aware that if any of the foregoing information is willfully false I am

subject to punishment.

____________________________________ ____________________________________

Date Signature of Applicant (sign only in

the presence of a Notary Public)

____________________________________ ____________________________________

Notary Public Date

Notary Seal:

New Jersey Administrative CodeTitle 13 - LAW AND PUBLIC SAFETYChapter 88 - OFFICE OF INSURANCE FRAUD PROSECUTORAppendix - APPENDIX