Property Damage Or Loss Claim Form - New York City
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4Office of the New York City Comptroller
1 Centre Street
New York City Comptroller
New York, NY 10007
Scott M. Stringer
Form Version: NYC-COMPT-BLA-PD1-M
Property Damage or Loss Claim Form
Claim must be filed in person or by registered or certified mail within 90 days of the occurrence at the NYC
Comptroller's Office, 1 Centre Street, Room 1225, New York, New York 10007. It must be notarized. If claim is
not resolved within 1 year and 90 days of the occurrence, you must start legal action to preserve your rights.
TYPE OR PRINT
I am filing:
On behalf of myself.
On behalf of someone else. If on someone else's
Attorney is filing.
behalf, please provide the following information.
Attorney Information (If claimant is represented by attorney)
Last Name:
First Name:
Firm or Last Name:
Firm or First Name:
Relationship to
the claimant:
Address:
Address 2:
Claimant Information
City:
*Last Name:
State:
*First Name:
Zip Code:
Address:
Tax ID:
Address 2:
Phone #:
City:
Email Address:
State:
Zip Code:
Country:
Date of Birth:
Format: MM/DD/YYYY
Soc. Sec. #
HICN:
(Medicare #)
Format: MM/DD/YYYY
Date of Death:
Phone:
Email Address:
Occupation:
City Employee?
Yes
No
NA
Gender
Male
Female
Other
* Denotes required field(s).
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