Memo on water main additions and retaining wall project, May

NYC 9/11 Public Portal Document

03/10/2024 00:40 212-669-4980 PAGE 07/25

Office of the New York City Comptroller ■■■' -■ CotnptroUei' 1 Centre Street -y' .lolin <?. Lhi New York, NY WOO?

ln$arance Information City vehicle informatiort Do you have insurance? r Yes C No Plate #; I........ I Did you report your accident to your insurance C Yes f No company? Were you paid by your insurance company? Yes C No City Driver Last Name: Is payment pertding? CYes rNo City Driver First Deductible Amount Name; Insurance Company Name: ________________________________ •Total Amount asimed: Address: Address 2: Format: Do nof include’S" or".’ City; State 2ip Code: Policy#: Phone »: Agent Name;

Date Signature or Claimant

State of New York County of

I. ig^g-z_ _________ , being duly sworn depose and say tlrat 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.., .. S„ ..3™. ..<^1.^

Signature of Claimant__ signature of nota.^^^ I

MARStNHK DESAI notary public of new YORK NO. 03 4865859 qualified in BRONX COUNTY COMMISSION EXPIRES SEPT 15. 2014

* Denotes required nefd(s}. Page 4 of4

NYC-WTC_000159264