Pedicab Accident Report - Nyc Department Of Consumer Affairs Page 2
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1
2ACCIDENT INFORMATION (Continued)
Briefly describe how the accident occurred:
Describe actions taken after the accident:
WITNESSES
Name of Witness:
Address of Witness:
Telephone Number:
Name of Witness:
Address of Witness:
Telephone Number:
PEDICAB OWNER AFFIRMATION – Please read and sign below.
I affirm that I am the owner of the pedicab business or an agent duly authorized by the owner to complete and submit this form. I am responsible for the entries
made. I also affirm that I have personally reviewed all of the information entered, and it is true, correct, and complete to the best of my knowledge
Name of Pedicab Owner or Agent (Print):
Signature:
Date:
PEDICAB DRIVER AFFIRMATION – Please read and sign below.
I affirm that I am the pedicab driver involved in the accident described in this form. I am responsible for the entries made. I also affirm that I have personally
reviewed all of the information entered, and it is true, correct, and complete to the best of my knowledge.
Name of Pedicab Driver (Print):
Signature:
Date:
PENALTY FOR FALSE STATEMENTS: It is against the law to make a statement in this form that you know is false. If you make a statement that you know is
false, you may be punished.
Under Sections 210.45 and 175.30 of the New York Penal Law, you may be:
▪
fined up to $1000 and / or
▪
sent to jail for up to one year
Under Section 175.35 of the New York Penal Law, you may be punished if you:
▪
make a statement that you know is false and / or
▪
make the statement because you intend to mislead the Department of Consumer Affairs
Under Section 175.35 of the New York Penal Law, you may be:
▪
fined up to $5000 or
▪
fined an amount that is twice the amount of money you received by making the false statement and / or
▪
sent to jail for up to 4 years
The Department of Consumer Affairs may also punish you for making a false statement on this form. These punishments may include:
▪
fines or penalties of up to $500 for each false statement
▪
permanent loss (revocation) of your license
09/2015
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