Nys Department Of Transportation Small Claims Form (Page 4 of 4) in pdf

Nys Department Of Transportation Small Claims Form Page 4

4. Description of Damage:

Please list all damages and attach documentation.

If the claim is in excess of $200 this claim form must be accompanied by either one of the

following:

• two estimates prepared by established businesses; or

• one copy of paid bill which contains verified information that the bill has been paid.

Claims under $200 can be accompanied by one (1) estimate or one (1) paid bill.

If the claim is for replacement of a tire, the estimate(s) must contain a statement to the effect

that the damaged tire could not be repaired. In addition, the estimate(s) must reflect a

deduction for depreciation, which must be made by a garage, service station, etc.:

5. Total Amount of Damages: $

(this blank must be filled in).

6. State Vehicle Information (if applicable):

If a State vehicle was involved, give the name of the operator, license plate, or some other

identification:

7. Witnesses to the incident:

Please provide names, addresses, and telephone numbers, if known. List any police agency

notified.

THE UNDERSIGNED IS THE OWNER OF THE VEHICLE OR PROPERTY REFERENCED

IN ITEM 1 AND UNDERSTANDS THAT FALSE STATEMENTS MADE IN THIS FORM

ARE PUNISHABLE AS A CLASS A MISDEMEANOR PURSUANT TO SECTION 210.45

OF THE PENAL LAW. ACCORDINGLY AND WITH NOTICE OF THE FOREGOING, I

HEREBY AFFIRM THAT ALL OF THE STATEMENTS CONTAINED IN THIS FORM ARE

TRUE, UNDER PENALTY OF PERJURY, THIS _____ DAY OF _______________ 20 _____.

Signed:

Reminder: Send completed form to the appropriate Regional Office. See cover letter for

locations by county.

DC30-2 (4/15)

Nys Department Of Transportation Small Claims Form Page 4