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 04/25

Office of the New York City Compfroltcr ■ /./V' ■ '-'I New York Cirv Cofltptj'oHer 1 Centre Street JohnC.Uli’ New York, NY ’COO?

Forn Version: NYC-COMPT-BIA-PDI-M

Property Damage or Loss Claim Form Claim must be Ried in penoncr by r^gi'iterpd or certified moil within 90 days of theoceurrencest the NYC Comptroller’s Office. I Centre Street, Room 1225. New York, New York 10007. It must be notorized, if claim is not resolved within 1 year and 90 days of the oecurrence, you must start legal action to srsserve your rights. TYPE OR PRINT I am tiling: .'•On behalf of myself. On behalf of someone else, if on someone else's ■ behalf, please provide the following information. C Attorney is filing. Attorney Information (If claimant is represented by attorney) LastNarnc; Rodriguez First Name: Luis Firm or Last Name;

Relationship to Firm or First Name; seif the claimant: 1 Address; Address 2: Claimant Information City: •Last Name: Rodriguez State: •First Name: Luis Zip Code; Address: PH Tax ID: Address 2; Phone City: Bronx Email Address:

State: NEW YORK Zip Code: 104«3 country; USA Date of Birth: Fermat: IVBIA^/YYYY Soc,Sec.« t" PH HICN: (Medicare «) n/a

Date of Death: n/a ________ [ftwy MM/oo/yyyy Phone; Email Address: PH “1= Occupation: Octcc?,v<__ Chy Employee? C Yes (5 No r NA Gender <9 Mate C Female C Other

• Oei>ote$ nqttM neWs). Pti9ei«f4

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