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 • Nev Fork City C'o:ntrollo I Centre Street •F ;ohm C. Lm New York, NY 10007

Insurance Information City vehicle information I......,•........ - ._.._ ... Do you have insurance? C Yes (No Mate a: Did you report your accident to your insurance {" Yes !" No company? ~~.._ ... «..._.. ---__-- Were you paid by your insurance company? "' Yes C'No City Driver Last ---_ Name: Is payment pending? {' Yes (No No City Driver First Deductible Name. Insurance Name: Total Amount Claimed: _..--..._...._ Address: Address 2: Format: Donor include'S"or' City: State: Zip Code: Policy #: Phone s: Agent Nan

'3 . -~ Date Signature of Claimant

State of New York County of

I, 4J. _... .. - , being duly sworn depose and say that? 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 claime~nt--- Signature of Weimar

MARSINH K DESAI NOTARY PUBLIC OF NEW YORK NO.03 A885859 QUALir WED IN BRONX COUNTY COPJiMIS.,ON EXPIRES SEPT 15, 2tl1a

Denotes required f eld(s3. Pape 4 af4

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NYC-WTC 000159264