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
• 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
7. Witnesses to the incident:
Please provide names, addresses, and telephone numbers, if known. List any police agency
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 _____.
Reminder: Send completed form to the appropriate Regional Office. See cover letter for
locations by county.