City Employment Claim Form

New York City Comptroller Scott M. Stringer

Office of the New York City Comptroller 1 Centre Street

New York, NY 10007 Form Version: NYC-COMPT-BLA-HC-LE

City Employment Claim Form

For most claims, under GML ? 50-e, a notice of claim must be filed within 90 days of the occurrence. A notarized notice of claim can be filed in person or by registered or certified mail at the NYC Office of the Comptroller, 1 Centre Street, Room 1225, NY, NY 10007. For most claims, if the claim is not resolved, legal action must be started within one 1 year and 90 days of the occurrence.

TYPE OR PRINT ALL FORM ENTRIES

I am filing: On behalf of myself.

Attorney is filing.

On behalf of someone else. If on someone else's behalf, please provide the following information:

Last Name:

First Name: Relationship to the claimant:

Attorney Information if represented by attorney

+Firm or Last Name: +Firm or First Name: +Address: Address 2:

Claimant Information

+City: +State:

*Last Name:

+Zip Code:

*First Name:

Tax Id:

*Address:

+Phone:

Address 2:

+Email Address:

*City:

*State:

*Zip Code: *Country: Date of Birth: Soc. Sec #: *Phone:

USA

Format: MM/DD/YYYY

The time and place where the claim arose

*Incident Date from: *Incident Date to: *Incident Location:

Format: MM/DD/YYYY Format: MM/DD/YYYY

*Email Address:

Address:

Occupation:

Current City Employee?

Yes

No

NA

Current Agency:

Address 2: City: State: Borough:

Gender:

Male

Female

Other

* Denotes required fields. + Denotes field that is required if Attorney is filing.

New York City Comptroller Scott M. Stringer *Nature of Claim/Description of Claim

Office of the New York City Comptroller 1 Centre Street

New York, NY 10007 Form Version: NYC-COMPT-BLA-HC-LE

Attach extra sheets if more room is needed.

What agency/employer are you making this claim against?

*Agency: Address: Address 2: City: State: Zip Code:

Work days lost: Amount Earned Weekly: Amount Earned Yearly:

Were you employed by a City Contractor at the time of claimed occurrence? ++Contractor Name:

Yes

No

*Denotes required field ++Denotes field that is required if you were employed by a City Contractor.

New York City Comptroller Scott M. Stringer

Office of the New York City Comptroller 1 Centre Street

New York, NY 10007 Form Version: NYC-COMPT-BLA-HC-LE

Salary/Benefit Claimed Damages

Overtime: Compensatory time: Differential: Annual Leave/Vacation: Sick Leave: Salary:

Date From: Date To: Amount: Total:

Additional Claimed Damages

Specify: Specify: Specify: Specify: Specify:

*Total Claimed Amount:

Amount: Total:

Date State of New York, County of

Signature of Claimant

I,

being duly sworn depose and say that I have read the foregoing

NOTICE OF CLAIM and know the contents thereof: that same is true to the best of my own knowledge, except as to the matter here stated to be alleged upon information and belief, and as to those matters. I believe them to be true.

Signature of Claimant

Sworn before me this day Signature of notary

*Denotes field that is required.

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