Notice of Claim Request from Comptroller, May 2005

NYC 9/11 Public Portal Document

PROPERTY DAMAGE CLAIM AGAINST THE CITY OF NEW YORK M*. * FOR WATER DAMAGE OR LOSS . TO THE COMPTROLLER OF THE CITY OF NEW YORK; I HEREWITH PRESENT MY CLAIM AGAINST THE CITY OF t YORK FOR PROPERTY DAMAGE.

Telephone # 17/0 ^3.-^ - -j? Print Name AY F Borne Business I reside at Z> >//i / z/ A/ y ilumber Street City Sta te Zip My damaged property is located at Number Street City State Zip and vas damaged on

PLEASE INDICATE THE CAUSE OF THE WATER DAMAGE: NEW YORK CITY WATERMAIN BREAK ['^r NEW YORK CITY SEWER OVERFLOW [ ] STREET FLOODING ( } ERRCNECUS THREE-D.'.Y NOTICE r ] DESCRIBE IN DE TA II HOW YOUR PROPERTY WAS DAMAGED: .

/yp/i/' 7i'.‘F/.',F h i?Af '/^tf i> f, Ti/3L2>m C A0 <A di e-f 11//r^ <5/} cv o /-/’lfi .>01 /'i: DID YOU REPORT THE INCIDENT TO THE DEPARTMENT OF ENVIRONMENTAL F^RI^CTION? Yes t^} No [ ] Date reported / - 2 " £>3"_______ Complaint Numberls) _______ 'T*'."’"' ----- ----- " O'. CHECK BOX BELOW WHICH-DESCRIBES YOUR PROPERTY: ' .. ... Apt. Building [ ] Retail Store Private House [ ] Commerciai/Euilding [ } Other I ] Describe ______________________________ , "'}7, ANY HISTORY OF WATER DAMAGE? Yes [ ] No [V'j . If yes, give date’fs'r of previous vater damag ' _________________ // 0_________________________________ City Claim f (s) ________________________ WAS IT RAINING AT THE TIME OF THE INCIDENT? Yes [ ] No [/] . INDICATE HOW THE WATER ENTER THE PROPERTY: Basement Trap [ ]Toilet [ ]Sink[ ]Bathtub f J Foundation [ ] Walls [ } Sideva. Gratings [ ] Cellar Door f ] Other [ 1 DESCRIBE BELOW ■J _____________ /2>d r// PA/ri /\ (< J V I WHAT WAS THE LEVEL OF THE WATER IN THE PREMISES? ______________________________________ HOW WAS THE WATER REMOVED? /3/1lLrF P ru 7________HOW LONG WAS WATER IN PREMISES?S WAS THERE ANY STRUCTURAL DAMAGE TO THE PROPERTY? Yes I ] No [/.'] If yes. Describe in deta

WAS ANY OF THE DAMAGED PROPERTY SOLD AT SALVAGE? Yes / 1 No [/] If yes, amount received 9________________ DID YOU HAVE INSURANCE COVERAGE FOR THE INCIDENT? Yes [ ] No of} If yes, state the name a. address of your insurance company ________________ ____________________ amount paid $ Claim Pending [ } Policy Limit

WITNESS (ES) --- ------------------------------------------------------ AMOUNT OF CLAIM AGAINST NEW YORK CITY CERTIFICATION

Date 2 Signature of Claiaant X

being duly svom depose and say that I read the foregoi. NOTICE OF CLAIM and knov the contents thereof; that same is true to the best of my O' knowledge, except as to the matter therein stated to be alleged upon information and belief, a: to those matters,, I believe it to be true.

SIGNATURE OF CLAIMANT X_

IMPORTANT: IF CLAIM IS NOT SETTLED, YOU MUST START LEGAL ACTION WITHIN ONE (1) YEAR AND 90 DA: FROM THE DATE OF OCCURRENCE.

IJOTARY PUBLIC STAMP: SWORN TO BEFORE ME THIS «M?«Wtt.wn«8tess “'isassss'” DAY OF 20<^

SIGBATUPE OF NOTARY PUBLIC

INSTRUCTIONS FOR FILING THIS CLAIM This claia must be filed in duplicate either in person or by Registered or Certified Mail vith: 90 days from the date of damage at the Office of the Comptroller, Municipal Building, Roc 1225S, 1 Centre Street, Nev York, NY 10007-2341.

(CONTINUED ON REVERSE SIDE)

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