OFFICE OF THE COMPTROLLER CITY OF NEW YORK NOTICE OF CLAIM CLAIMANT INFORMATION CLAIMANT'S NAME: STREET TEL. #: ( ADDRESS: _____________________________________________________________ CITY: SOC. STATE: SEC. # or )_____________ TAX I.D. #: ZIP:___________ ___________________________________________________ CLAIM INFORMATION CITY AGENCY INVOLVED:___________________________________________________________________ NATURE OF CLAIM:(ATTACH ADDITIONAL SHEET(S) OF PAPER, IF NECESSARY) TOTAL AMOUNT CLAIMED: $______________________________________________________ IF MORE THAN ONE ITEM IS INCLUDED IN THE TOTAL AMOUNT CLAIMED, SUPPLY BREAKDOWN OF AMOUNTS AND SPECIFY ITEMS: (ATTACH ADDITIONAL SHEET(S), IF NEEDED) ITEM AMOUNT 1. $_________________ 2. $_________________ 3. $_________________ 4. $_________________ 5. $_________________ PLEASE ATTACH COPIES OF SUPPORTING DOCUMENTATION, PREVIOUS CORRESPONDENCE, INVOICES, ETC. __________________________________________________________________________ CLAIMANT’S SIGNATURE:____________________ SS: STATE OF N.Y. CITY OF N.Y. SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , 20 NOTARY TO: OFFICE OF THE COMPTROLLER DIVISION OF LAW - RM.1225 South 1 CENTRE STREET NEW YORK, N.Y. 10007 TELEPHONE # (212) 669-4736 American LegalNet, Inc. www.FormsWorkFlow.com