This form is unofficial and provided primarily for pro se litigants. It should be completed in accordance with the substantive pleading requirements of Court of Claims Act section 11(b). State of New York Court of Claims ___________________________________________ ________________________________, ________________________________, Claimant(s) v. ________________________________, ________________________________, Defendant(s) Claim _____________________________________ 1. The post office address of the claimant (you) is_______________________________ _____________________________________________________________________________. 2. This claim arises from the acts or omissions of the defendant. Details of said acts or omissions are as follows (be specific):________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. 3. The place where the act(s) took place is (be specific): ____________________________ ______________________________________________________________________________ _____________________________________________________________________________. 4. This claim accrued on the ____ day of _____________, ________ at _______ o'clock. American LegalNet, Inc. www.FormsWorkflow.com 5. Identify the items of damage or injuries claimed to have been sustained: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6. (Check appropriate box): This Claim is served and filed within 90 days of accrual. OR A Notice of Intention to File a Claim was served on _____________________, which was within 90 days of accrual. OR This is a claim by a correctional facility inmate to recover damages for injury to or loss of personal property and it is served and filed within 120 days of the exhaustion of claimant's administrative remedies. By reason of the foregoing, Claimant was damaged in the amount of $______________, and Claimant demands judgment against the Defendant(s) for said amount. _____________________________________ Claimant VERIFICATION STATE OF NEW YORK ) ss: COUNTY OF ____________) __________________________________, being duly sworn, deposes and says that deponent is the Claimant in the within action; that deponent has read the foregoing Claim and knows the contents thereof; that the same is true to deponent's own knowledge, except as to matters therein stated to be alleged upon information and belief, and that as to those matters, deponent believes it to be true. _________________________________________ Sworn to before me this ____ day of _________________, ______. ___________________________ Notary Public, State of New York SERVICE AND FILING INSTRUCTIONS You must serve a copy of the claim in accordance with Court of Claims Act section 11(a) and you must file the original and two copies, with proof of service, and the filing fee of $50.00 or an application for waiver or reduction of the filing fee, with the Clerk of the Court of Claims. FAILURE TO EFFECT PROPER AND TIMELY SERVICE AND FILING MAY RESULT IN DISMISSAL OF YOUR CLAIM New York State Court of Claims Justice Building, P.O. Box 7344 Albany, New York 12224 (518) 432-3411 American LegalNet, Inc. www.FormsWorkflow.com