Form Mv-2001 - Claim And Release Form
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1
2CLAIM AND RELEASE FORM
INSTRUCTIONS: Please complete both sections on page 1 of this form, and have both sections notarized. Return 2 copies with original
signatures along with the request for Taxpayer Identification Number and Certification (W-9) to: Department of Motor
Vehicles, Legal Bureau, 6 Empire State Plaza, Room 522, Albany NY 12228. To obtain form W-9 go to
CLAIM FORM SECTION
STATE OF NEW YORK
)
)
ss:
_________________________________________________
(DATE OF BIRTH OR LICENSE ID NUMBER)
COUNTY OF
)
I ____________________________________________________________________, ___________________________________, reside at
(SOCIAL SECURITY NUMBER)
(NAME)
(
)
________________________________________________, _____________________, _______, ___________, ______________________
(STATE)
(ZIP CODE)
TELEPHONE NO. (OPTIONAL)
(ADDRESS - CITY, TOWN OR VILLAGE)
(COUNTY)
and present to the Department of Motor Vehicles, State of New York, a verified claim, in the sum of ___________________ dollars
($________________) for damages sustained by me as the result of a wrongful act of an officer, employee or agent of the State of New York.
The details explaining this incident are as follows (please type or print clearly; if you need more space, attach a separate page):
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Subscribed and sworn to before me this
(CLAIMANT SIGNATURE)
(The facts stated above must constitute a legal claim)
_________day of________________________, in the year __________.
_____________________________________________
(NOTARY PUBLIC)
RELEASE FORM SECTION
(This release is not binding on the claimant until the claim is approved and paid.)
In consideration of the sum of _________________________ DOLLARS ($_______________) hand paid to me by the State of New York
(receipt of which I hereby acknowledged), I do for myself, my heirs, executors, administrators and assigns, release and discharge the said State
of New York, its officers, agents and employees, from all claims, demands and liability of every kind and nature, legal or equitable, occasioned
by or arising out of the facts set forth in the foregoing claim. In case any claim shall have been filed by me with the Clerk of the Court of
Claims for said damages at any time prior to the date of this release, I consent and stipulate that an order may be made by the Court of Claims,
dismissing said claim upon the merits, without notice to me.
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(CLAIMANT LEGAL SIGNATURE)
IN WITNESS WHEREOF, I have hereunto set my hand and seal this __________ day of ________________, in the year ___________.
STATE OF NEW YORK
)
)
ss:
COUNTY OF
)
On this _________ day of ___________________, in the year ___________, before me, the subscriber, personally appeared
___________________________________, to me personally known to be the person described in and who executed the foregoing release,
and he/she duly acknowledged to me that he/she executed the same.
(NOTARY PUBLIC)
MV-2001 (8/15)
dmv.ny.gov
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