Notice of Claim Request from Comptroller, May 2005

NYC 9/11 Public Portal Document

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

/L V1 l T [7 _._._._._._._._._ T/ / /i / i 0 Telephone N L P11 Print Name _._._._..._._._._._ _ I reside at Home Business PII somber Street My damaged property City State Zip is located at A ((L Number Street and was damaged on City State Zip

PLEASE INDICATE THE CAUSE OF THE WATER DAMAGE: NEW YORK CITY WATERMAIN BREAK (k-f' NEW YORK CITY SEWER OVERFLOW ( 1 STREET FLOODING f 1 LRRCNECUS THREE-LL:Y NOTICE ( J DESCRIBE IN DETAIL HOW YOUR PROPERTY WAS DAMAGED: I /

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( /. D 4 4 C/ LM/ /t - Lill ji DID YOU REPORT THE INCIDENT /fG%a.• , .- TO THE DEPARTMENT OF Date reported __J - 3 ENVIRONMENTAL PROTECTION? Yes 0 5 Complaint Number(s) FBI No [ ] CHECK BOX BELOW WHICH 2 'k -DESCRIBES YOUR PROPERTY: "`— Apt. Buildin9 [ 1 Retail Store (Private House ( 1 ' Other ( 1 Describe Commercial?- •'ilding f 1 ANY HISTORY OF WATER DAMAGE? Yes f ] No (V]. If yes, give date'(;)' of previous water damag• WAS XT RAINING AT THE City Claim / (s) TIME OF THE INCIDENT? Yes ( THE PROPERTY: Basement Tra I No (Xi. INDICATE HOW THE WATER ENTER p Gratings ( J Cellar Door p 1 )Toilet ( ]Sink( )Bathtub ( )Foundation ( ] Walls ( J Sideva. I I Other ( I DESCRIBE BELOW I;• ,e c P-, U or r ,/ (3O,/ 7L n P ,~ ' ,7 fv L WHAT WAS THE LEVEL OF THE WATER IN TNF ° EWICVS~ HOW WAS THE WATER REMOVED?Jj/},L,,r D rV 7 HOW LONG WAS WATER IN WAS THERE ANY STRUCTURAL PREMISES? S ,[ DAMAGE TO THE PROPERTY? Yes [ I No [>('I If yes, Descr ib e in deta WAS ANY OF THE DAMAGED PROPERTY SOLD AT SALVAGE. Yes [ 1 No (/] If yes, $ amount received DID YOU HAVE INSURANCE COVERAGE FOR THE INCIDENT? address of your insurance company Yes ( I No b(1 If yes, state the name a. Claim Pending [ 1 P olicy Limit amount paid $

WITNESS (ES)

AMOUNT OF CLAIM AGAINST NEW YORK CITY $44A -7' /•-O CERTIFICATION 7 Date 1 0 0 Signature of Claimant X

b ng duly epose NOTICE OF CLAIM and know at I e the content e1thereof;sworn knowledge, except as to the matter thatdsame isand true saytto the e b adest , of my oo1 therein stated to be alleged to those matters, I upon information and belief, believe it to be true. a;

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

NOTARY PUBLIC STAMP:

SWORN TO BEFORE ME THIS /(

"l0 ~.~raane.roAc UNM*M vim: G DAY OF __________ - 200'

~irl~ j SIGNATURE OF NOTARY PUBLIC

INSTRUCTIONS FOR FILING THIS CLAIM This claim must be filed in duplicate either in person by 90 days from the date of gistered or ied damage at the Office mptr oller 1225$, 1 Centre Street, New York, Municipal f Buildin g viRoc NY 10007-2341.

(CONTINUED ON REVERSE SIDE)

NYC-WTC 000159216