Form Mv-2001 - Claim And Release Form (Page 2 of 2) in pdf

TO BE COMPLETED BY OFFICE WHERE INCIDENT OCCURRED

Claimant Name:

My review reveals the following facts (if additional space is needed, attach a separate page):

________________________________________________________________________________________________________________

(PRINT NAME)

(SIGNATURE)

(TITLE)

(DATE)

TO BE COMPLETED BY CENTRAL OFFICE

This claim for $300 or less, for damages to the personal property of a DMV employee, is approved.

This claim, which exceeds $1,000, but is not more than $5,000, is approved by DMV. It will be sent to the State Attorney General

for review and approval, and to the Office of the State Comptroller for final approval and payment.

This claim, which is not more than $1,000, is approved by DMV. It will be sent to the Office of the State Comptroller for final

approval and payment.

On behalf of the Commissioner of the Department of Motor Vehicles, State of New York, I have reviewed the facts in connection with this

claim and the resulting damages. I find that the facts constitute a just and legal claim against the State of New York as provided in paragraph

12A or 12D of Section 8 of the State Finance Law, and that the damages are fair and reasonable. Payment is recommended.

(LEGAL BUREAU SIGNATURE)

(DATE)

(DIRECTOR OF FISCAL MANAGEMENT SIGNATURE)

(DATE)

CLAIM AND RELEASE

– against –

STATE OF NEW YORK

DEPARTMENT OF MOTOR VEHICLES

Amount of Claim $_____________________

APPROVED:

_________________________________________ day of _________________________, in the year ___________

___________________________________

APPROVED:

_________________________________________ day of _________________________, in the year ___________

________________________

Attorney General

By:

(ASSISTANT ATTORNEY GENERAL)

MV-2001 (8/15)

PAGE 2 OF 2

Form Mv-2001 - Claim And Release Form Page 2