DEP update on April 30, 2014 storm response

NYC 9/11 Public Portal Document

From: 05/21/2014 10:56 #965 P.007/007 Offlceofthe New' ’orkCIty Comptroller e New Yortt City Comptroller 1 1 Centra Street 5 Scott M. Stringer Water Damage Infonnation New York, NY 10007 . t

KaveyoufBedadaiffiwithany other parties? If soj please Insurance Coverage (If any) provide name end address._________________________ last Name: Insurance Company ru 5 I le RrstName; ________________________________ Address Oq, Jf 3A6, Address 2; Address 2: ________________________________ aty: Heir leu W He Cfty: ________________________________ State: Zip Code: I? ____________________________ Zip Code ________________________________ Amount Paid: » Policy Umlt tt o? <- > • co

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Date SignaWfe of Clalm^t

State of New York

I l*^^*^**"" being duly sworn depose and say that I have read the foregoing

NOTCE OF CLAWCand know the contents thereof: that same is true to the best of my own knowledge, except as to ti e matter here stated tobaallegeduponlnfbrm8tion8ndbeHef.anda$tothoseiT»a«ers,lbeIlewethemtobetroe. I Sworn before me tWs day.

Sp.^ signature of

UaA2t>uSc3t5U. COMMONWEALTH OF PBiNSYLVAWA Notarial Seal Yctorta A St John, Notary Pubfc Doylestown Boro, Bucks County J MyCorronlsslonB^MayiaiS •I>titet9»retiulredfleltl(t). MBISBt, FEIileVlVANM ASSr^WN W NOTARIES (•age 5 of5

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