New York State Department of Motor Vehicles CLAIM AND RELEASE FORM INSTRUCTIONS: Please complete both sections on page 1 of this form, and have both sections notarized. Return 2 copies with original signatures to: Department of Motor Vehicles, Legal Bureau, 6 Empire State Plaza, Room 526, Albany NY 12228. CLAIM FORM SECTION STATE OF NEW YORK COUNTY OF ) ) ) ss: _________________________________________________ (DATE OF BIRTH OR CLIENT ID NUMBER) I ____________________________________________________________________, ___________________________________, reside at (SOCIAL SECURITY NUMBER) (NAME) ( ) ________________________________________________, _____________________, _______, ___________, ______________________ (ADDRESS - CITY, TOWN OR VILLAGE) (COUNTY) (ZIP CODE) (STATE) TELEPHONE NO. (OPTIONAL) and present to the Department of Motor Vehicles, State of New York, a verified claim, in the sum of ___________________ dollars ($________________) for damages sustained by me as the result of a wrongful act of an officer, employee or agent of the State of New York. The details explaining this incident are as follows (please type or print clearly; if you need more space, attach a separate page): ± Subscribed and sworn to before me this (CLAIMANT SIGNATURE) (The facts stated above must constitute a legal claim) _________day of________________________, in the year __________. _____________________________________________ (NOTARY PUBLIC) RELEASE FORM SECTION (This release is not binding on the claimant until the claim is approved and paid.) In consideration of the sum of _________________________ DOLLARS ($_______________) hand paid to me by the State of New York (receipt of which I hereby acknowledged), I do for myself, my heirs, executors, administrators and assigns, release and discharge the said State of New York, its officers, agents and employees, from all claims, demands and liability of every kind and nature, legal or equitable, occasioned by or arising out of the facts set forth in the foregoing claim. In case any claim shall have been filed by me with the Clerk of the Court of Claims for said damages at any time prior to the date of this release, I consent and stipulate that an order may be made by the Court of Claims, dismissing said claim upon the merits, without notice to me. ± (CLAIMANT LEGAL SIGNATURE) IN WITNESS WHEREOF, I have hereunto set my hand and seal this __________ day of ________________, in the year ___________. STATE OF NEW YORK COUNTY OF ) ) ) ss: On this _________ day of ___________________, in the year ___________, before me, the subscriber, personally appeared ___________________________________, to me personally known to be the person described in and who executed the foregoing release, and he/she duly acknowledged to me that he/she executed the same. MV-2001 (10/07) (NOTARY PUBLIC) www.nysdmv.com PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com TO BE COMPLETED BY OFFICE WHERE INCIDENT OCCURRED Claimant Name: My review reveals the following facts (if additional space is needed, attach a separate page): ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ± (PRINT NAME) (TITLE) (SIGNATURE) (DATE) TO BE COMPLETED BY CENTRAL OFFICE This claim for $300 or less, for damages to the personal property of a DMV employee, is approved. This claim, which exceeds $1,000, but is not more than $5,000, is approved by DMV. It will be sent to the State Attorney General for review and approval, and to the Office of the State Comptroller for final approval and payment. This claim, which is not more than $1,000, is approved by DMV. It will be sent to the Office of the State Comptroller for final approval and payment. On behalf of the Commissioner of the Department of Motor Vehicles, State of New York, I have reviewed the facts in connection with this claim and the resulting damages. I find that the facts constitute a just and legal claim against the State of New York as provided in paragraph 12A or 12D of Section 8 of the State Finance Law, and that the damages are fair and reasonable. Payment is recommended. ± (LEGAL BUREAU SIGNATURE) (DATE) ± (DIRECTOR OF FISCAL MANAGEMENT SIGNATURE) (DATE) CLAIM AND RELEASE – against – STATE OF NEW YORK DEPARTMENT OF MOTOR VEHICLES Amount of Claim $_____________________ APPROVED: _________________________________________ day of _________________________, in the year ___________ ___________________________________ APPROVED: _________________________________________ day of _________________________, in the year ___________ ________________________ Attorney General By: ± MV-2001 (10/07) (ASSISTANT ATTORNEY GENERAL) PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com