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Proof of Claim Form
Full Name
Street Address
City
State
Zip Code
Please provide a good faith estimate of the total amount of costs and expenses that you incurred as a result of the displacement from your apartment at 2 Gold Street or 201 pearl Street between October 29, 2012 and February 15, 2013.
Current Mailing Address
Damages
Estimated Damage Amount
Do you have documentation such as credit card statements, invoices, receipts, contracts, new lease agreements, ect., to support your damage estimate?
If you received funds from any collateral source including insurance, FEMA, or other government or relief agency, that were intended to compensate you for losses and expenses resulting from Hurricane Sandy, please provide an estimate of the total amount of funds that you received.
Estimated Amount
If there is additional information you would like to provide at this time, please fill out the questionnaire ‘Individual Costs and Expenses’ by clicking here.
Date
Signature/Initial (type your initials)
E-mail Address
Telephone Number
On October 29, 2012 (Hurricane Sandy) which building did you reside?
On October 29, 2012 (Hurricane Sandy) what was your apartment #?
On October 29, 2012 (Hurricane Sandy) how many people, including yourself, resided in your apartment?
