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INSTRUCTIONS : Please complete both sections of this form, have both sections notarized, and

INSTRUCTIONS : Please complete both sections of this form, have both sections notarized, and 2026

INSTRUCTIONS : Please complete both sections of this form, have both sections notarized, and Preview on Page 1

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The document is a Claim and Release Form for individuals seeking compensation for damages caused by an officer or employee of the State of New York. It includes sections for the claimant to provide personal information, details of the incident, and the claim amount. The release section outlines the terms under which the claimant releases the State from further liability upon payment. Notarization is required for both sections, and there are provisions for agency review and approval.

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Click ‘Get Form’ to open it in the editor.
In the CLAIM SECTION, fill in your name, address, and contact information. Ensure all details are accurate as they will be used for verification.
Specify the claim amount in both written and numerical form. Provide a brief description of the incident that led to your claim. If more space is needed, attach additional pages.
Sign the CLAIM SECTION where indicated. This signature must be notarized, so ensure you have a notary public present when signing.
In the RELEASE SECTION, acknowledge receipt of payment by filling in the amount received. Sign this section as well, ensuring it is also notarized.
Complete any required agency sections after submitting your form for approval. Make sure to return three copies with original signatures as instructed.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (48 Votes)

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