Fillable Printable Form MV-2001 - Claim and Release Form - New York

Form MV-2001 - Claim and Release Form - New York

INSTRUCTIONS: Please complete both sections on page 1 of this form, and have both sections notarized. Return 2 copies with original

signatures along with the request for Taxpayer Identification Number and Certification (W-9) to: Department of Motor

Vehicles, Legal Bureau, 6 Empire State Plaza, Room 522, Albany NY 12228. To obtain form W-9 go to www.irs.gov.

CLAIM FORM SECTION

STATE OF NEW YORK )

) ss: _________________________________________________

COUNTY OF )

I ____________________________________________________________________, ___________________________________, reside at

________________________________________________, _____________________, _______, ___________, ______________________

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):

STATE OF NEW YORK )

) ss:

COUNTY OF )

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.

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 SIGNATURE)

(The facts stated above must constitute a legal claim)

(CLAIMANT LEGAL SIGNATURE)

(NOTARY PUBLIC)

Subscribed and sworn to before me this

_________day of________________________, in the year __________.

_____________________________________________

(NOTARY PUBLIC)

MV-2001 (8/15)

PAGE 1 OF 2

www.dmv.ny.gov

IN WITNESS WHEREOF, I have hereunto set my hand and seal this __________ day of ________________, in the year ___________.

(NAME)

(ADDRESS - CITY, TOWN OR VILLAGE) (COUNTY)

(STATE)

( )

(ZIP CODE) TELEPHONE NO. (OPTIONAL)

(SOCIAL SECURITY NUMBER)

(DATE OF BIRTH OR LICENSE ID NUMBER)

CLAIM AND RELEASE FORM

TO BE COMPLETED BY OFFICE WHERE INCIDENT OCCURRED

My review reveals the following facts (if additional space is needed, attach a separate page):

________________________________________________________________________________________________________________

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.

TO BE COMPLETED BY CENTRAL OFFICE

o This claim for $300 or less, for damages to the personal property of a DMV employee, is approved.

o 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.

o 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.

MV-2001 (8/15)

(SIGNATURE)(PRINT NAME)

(DATE)(TITLE)

(LEGAL BUREAU SIGNATURE) (DATE)

(DIRECTOR OF FISCAL MANAGEMENT SIGNATURE) (DATE)

(ASSISTANT ATTORNEY GENERAL)

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:

PAGE 2 OF 2

Claimant Name: