Form Mv-2001.1 - Instructions For Filing A "Claim And Release Form" printable pdf download

INSTRUCTIONS FOR

FILING A “CLAIM AND RELEASE FORM”

Please follow these instructions for filling out the Claim and Release Form (

). The Claim and Release

MV-2001

Form should be completed only if your claim is for $5,000 or less.

You must submit

completed copies of the Claim and Release Form along with the

TWO

Request for Taxpayer

Filling out both forms completely and accurately will prevent

Identification Number and Certification (W-9).

delays in processing your claim to determine whether you should be awarded damages. To obtain form W-9 go

Claim Form Section:

1. Complete this section in full and have it notarized. You must have an

original

signature in this

section. A photocopied signature is not acceptable.

2. Describe in detail why you are filing the claim, including dates, times, and location. Be sure to explain

exactly what error or omission you believe DMV made. If necessary, attach additional pages of

explanation. Claims for damages involving money should be supported by documentation of the damages.

Release Form Section:

1. Complete this section of the form even if the claim you are making has not been approved and/or

paid. Be sure to have this section notarized.

2. Be sure to sign this section of the form. A photocopied signature is not acceptable.

CHECKLIST

After completing the Claim and Release form, check to see that you . . .

Filled in your:

name

state

Social Security Number

address

zip code

Telephone Number (optional)

city

date of birth or License ID Number

Completed two copies of the form with ORIGINAL signatures (no photocopied signatures).

Had both the Claim and Release sections notarized.

Signed both the Claim and Release sections.

Remember to attach documentation of lost wages, costs incurred, receipts, invoices, bills

(for example, taxi receipts, toll receipts, and phone bills) and any other relevant materials

that support your claim. Include the Vehicle Identification Number (VIN) and/or plate number

when appropriate.

Completed form W-9.

Mail

completed and signed copies along with the Request for Taxpayer Identification Number and Certification

two

(W-9) to: Department of Motor Vehicles, Counsel’s Office, 6 Empire State Plaza, Room 522, Albany NY 12228.

Note: Submitting form MV-2001 “Claim and Release Form” does not guarantee that you will be paid for your

claim. Staff from DMV’s Counsel’s Office and Office of Fiscal management will investigate the claim.

If the claim is for more than $1,000, it will also be sent to the New York State Attorney General’s Office.

If the claim is approved, the Office of the State Comptroller will send you a check. If the claim is denied,

DMV’s Counsel Office will contact you in writing. Please allow 4 to 6 weeks for the claim to be processed.

dmv.ny.gov

MV-2001.1 (8/15)

Form Mv-2001.1 - Instructions For Filing A "Claim And Release Form"

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