Fillable CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY (United Federation of Teachers)

Fill Online, Printable, Fillable, Blank CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY (United Federation of Teachers) Form

Use Fill to complete blank online UNITED FEDERATION OF TEACHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY (United Federation of Teachers)

On average this form takes 12 minutes to complete

The CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY (United Federation of Teachers) form is 1 page long and contains:

  • 0 signatures
  • 8 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your United Federation of Teachers forms online.

BROWSE UNITED FEDERATION OF TEACHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY (OP 504)
Claim for Loss or Damage to Personal Property form (OP504)
Page 1 of 2
New York City Department of Education - Division of Human Resources and Talent
HR Connect Medical, Leaves and Records Administration
65 Court Street, Room 201, Brooklyn, New York 11201
SECTION I: Applicant Information
LAST NAME FIRST NAME M.I.
STREET ADDRESS
APT. NUMBER
CITY STATE ZIP CODE
AREA HOME TELEPHONE NUMBER
FILE NUMBER EMPLOYEE ID
JOB TITLE: EMAIL ADDRESS:
SCHOOL CODE
SCHOOL TELEPHONE NUMBER
AREA
ISC/CFN DISTRICT
Claim related to LODI incident?
HR Connect LODI case#:
LODI approved by HR Connect?
Yes
No
Attach additional sheets if necessary.
Article Cost Date Purchased
Store and Location
SECTION III: To be completed by Claims Unit ONLY
Total Amount Claimed: $
Signature of Claimant Today's Date
Date Approved
Amount
Date Disapproved
Reviewed By
Yes
No
Date of incident
Description
of incident
Room number or place of loss or damage
Date and time reported to principal
No
Yes
Incident reported to police?
SECTION II: Items Claimed
Reimbursement for personal property is limited to $100.00 per person in any school year. Cash is not reimbursable. Only the loss of or damage to personal
clothing and personal accessories (e.g. handbags, wallets, eyeglasses, or umbrellas) are reimbursed.
The facts contained above are true to the best of my knowledge, information, and belief. I understand that the acceptance of payment for the amount allowed by
the Department of Education for this claim shall release the Department of Education from all liability for the loss of or damage to personal property arising out of
the incident described above. I also agree that in the event that lost property is later recovered and is returned to me, I shall reimburse the Department of
Education for any monies paid.
The facts provided in Sections I and II are substantially correct. Any exceptions are noted below.
Approval Recommended Disapproval Recommended for the Following Reason:
Today's Date
Signature of Principal
SECTION IV: Determination of Medical Claims Unit
Claim for Loss or Damage to Personal Property form (OP504)
Page 2 of 2
Instructions for Claim for Loss or Damage to Personal Property form (OP504)
1. Complete the application on the face of this form per the instructions below.
Section I: To be completed by the applicant
a. Provide your full name, mailing address, home and school contact information, file number, employee ID, job title, and
email address
b. In the space next to your school contact information, provide the following information:
i. Check (Yes/No) if claim is related to a LODI incident
ii. The LODI case number issued by HR Connect (if applicable)
iii. Indicate whether or not your LODI was approved by HR Connect
Section II: To be completed by the applicant
c. Provide the following information in the space provided (attach additional sheets if necessary):
i. Date of the incident
ii. Description of the incident
iii. Room number or place of loss or damage to property
iv. Date and time reported to principal
v. Indicate whether or not the incident was reported to police
a. Complete the table with the following information (attach additional sheets if necessary)
i. Article: Item lost or damage
ii. Cost: Amount paid for the item (in dollar) or amount paid to repair damaged item (if applicable)
iii. Date Purchased (if known)
iv. Store and Location: Place of business where item was purchased (if known)
Section III: To be completed by the applican't principal
2. Include proof of payment with your application. This can be an orginal or photocopy of the receipt.
IMPORTANT: The maximum reimbursement amount for a personal property claim submitted without proof of payment is $50 per
person in any school year.
3. Submit the completed form, including all required signatures and supporting documentation to HR Connect:
New York City Department of Education
HR Connect Medical, Leaves and Records Administration
65 Court Street, Room 201
Brooklyn, New York 11201
b. Indicate the total amount claimed. Note that if an item was repaired, only the cost of repairs will be reimbursed.
c. Employee must sign and date
a. Check Approval/Disapproval and provide reason(s)
b. Principal must sign and date
Section IV: To be completed by the Claims office
Applicants should not complete this section. It is for official use only.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY (United Federation of Teachers)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 29 March 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document