ESD Reporting Form - Jan. 1, 2022

Information received from this form will be transmitted to the appropriate state agency in satisfaction of reporting requirements under Chapter 775 of the Health and Safety Code. This form is for the report required for January 1, 2024. If you wish to submit a report for a different year, contact SAFE-D at admin@safe-d.org.

Please familiarilze yourself with the form before you begin submitting answers, because there is no mechanism to save the form and return later.

Note: If there is a vacancy in a commissioner's spot, use "NA" in fields and "vacant@noemail.com" for the email address.

ESD Name (i.e., Buffalo County ESD No. 99)*

County or Counties in Which ESD is Located*

ESD Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

ESD email*

ESD phone*

Area CodePhone Number

ESD website

FireEmergency Medical ServiceBoth

Annual ESD Budget*

Tax rate (most recently adopted; i.e., $0.10/$100)*

Population of ESD

Area (sq. miles) of ESD

YesNo

If your ESD collects a sales tax, what is the rate of the sales tax? (i.e. 1/2 percent)

Name of Person Completing this Form*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

Name of Commissioner No. 1*

First NameLast Name

Role on ESD Board*

E-mail*