Property Damage Or Loss Claim Form - New York City Page 3
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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
Witness 1 Information
Witness 4 Information
Last Name:
Last Name:
First Name:
First Name:
Address
Address
Address 2:
Address 2:
City:
City:
State:
State:
Zip Code:
Zip Code:
Witness 2 Information
Witness 5 Information
Last Name:
Last Name:
First Name:
First Name:
Address
Address
Address 2:
Address 2:
City:
City:
State:
State:
Zip Code:
Zip Code:
Witness 3 Information
Witness 6 Information
Last Name:
Last Name:
First Name:
First Name:
Address
Address
Address 2:
Address 2:
City:
City:
State:
State:
Zip Code:
Zip Code:
Police Information
Please indicate which of the following reports you have
Accident Report
Police Officer Last
Name:
Aided Report
Police Officer First
Complaint Report
Name:
Shield Number:
Precinct:
Report Number:
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