Property Damage Or Loss Claim Form (Electronic Filing) {NYC-COMPT-BLA-PD1-D2}

New York City Comptroller Scott M. Stringer Office of the New York City Comptroller 1 Centre Street New York, NY 10007 Form Version: NYC-COMPT-BLA-PD1-M Property Damage or Loss Claim Form Claim must be filed in person or by registered or certified mail within 90 days of the occurrence at the NYC Comptroller's Office, 1 Centre Street, Room 1225, New York, New York 10007. It must be notarized. If claim is not resolved within 1 year and 90 days of the occurrence, you must start legal action to preserve your rights. TYPE OR PRINT I am filing: On behalf of myself. On behalf of someone else. If on someone else's behalf, please provide the following information. Last Name: First Name: Relationship to the claimant: Attorney is filing. Attorney Information (If claimant is represented by attorney) Firm or Last Name: Firm or First Name: Address: Address 2: Claimant Information *Last Name: *First Name: Address: Address 2: City: State: Zip Code: Country: Date of Birth: Soc. Sec. # HICN: (Medicare #) Date of Death: Phone: Email Address: Occupation: City Employee? Gender Yes Male No NA Other Format: MM/DD/YYYY Format: MM/DD/YYYY City: State: Zip Code: Tax ID: Phone #: Email Address: Female * Denotes required field(s). Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com New York City Comptroller Scott M. Stringer The time and place where the claim arose *Date of Incident: Time of Incident: Format: MM/DD/YYYY Format: HH:MM AM/PM Office of the New York City Comptroller 1 Centre Street New York, NY 10007 Property Clerk Voucher Number: District Attorney Release Number: Address: Address 2: *Location of Incident: City: State: Borough: *Manner in which claim arose: Attach extra sheet(s) if more room is needed. The items of damage claimed are (include dollar amounts): Attach extra sheet(s) if more room is needed. * Denotes required field(s). Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com New York City Comptroller Scott M. Stringer Office of the New York City Comptroller 1 Centre Street New York, NY 10007 Witness 1 Information Last Name: First Name: Address Address 2: City: State: Zip Code: Witness 2 Information Last Name: First Name: Address Address 2: City: State: Zip Code: Witness 3 Information Last Name: First Name: Address Address 2: City: State: Zip Code: Police Information Police Officer Last Name: Police Officer First Name: Shield Number: Precinct: Report Number: Witness 4 Information Last Name: First Name: Address Address 2: City: State: Zip Code: Witness 5 Information Last Name: First Name: Address Address 2: City: State: Zip Code: Witness 6 Information Last Name: First Name: Address Address 2: City: State: Zip Code: Please indicate which of the following reports you have Accident Report Aided Report Complaint Report Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com New York City Comptroller Scott M. Stringer Office of the New York City Comptroller 1 Centre Street New York, NY 10007 Insurance Information Do you have insurance? Did you report your accident to your insurance company? Were you paid by your insurance company? Is payment pending? Deductible Amount: Insurance Company Name: Address: Address 2: City: State: Zip Code: Policy #: Phone #: Agent Name: Yes Yes Yes Yes No No No No City vehicle information Plate #: City Driver Last Name: City Driver First Name: *Total Amount Claimed: Format: Do not include "$" or ",". _______________________________________________________ __________________________________________________________ Date Signature of Claimant State of New York County of I, _____________________________________________________, being duly sworn depose and say that I have read the foregoing NOTICE OF CLAIM and know the contents thereof: that same is true to the best of my own knowledge, except as to the matter here stated to be alleged upon information and belief, and as to those matters. I believe them to be true. Sworn before me this day____________________________________ Signature of Claimant______________________________________________ Signature of notary_________________________________________ * Denotes required field(s). Page 4 of 4