Town of Brookhaven
Long Island, New York
Vehicle Control
550 North Ocean Ave. Patchogue, NY 11772
(631) 451-6562 ABA-01 REV. 7/16
REQUEST FOR REMOVAL OF ABANDONED VEHICLES
I, the undersigned am the owner/ or authorized agent of the owner of the property on which the below
listed vehicle(s) is/ are abandoned. This/these vehicle(s), has/have remained on my property
for more than ninety-six (96) hours without permission, which pursuant to New York
State Vehicle and Traffic Law, Section 1224, Section 1.D, deems the vehicle(s) abandoned.
Accordingly, I hereby authorize the Town of Brookhaven to enter my property at any reasonable
time and remove any and all vehicles abandoned as defined in New York State Vehicle and Traffic
Law, Section 1224. I hereby agree to release indemnify, defend and hold harmless,
the Town of Brookhaven, and all its officers, agents, employees and/ or subcontractors from
any and all liability resulting from removal, towing and storage of said vehicles.
1. Name of Property Owner
____________________________________________________
2. Physical Address of Property
____________________________________________________
3. Mailing Address of Property Owner
___________________________________________
4. Contact Number w/Area Code
___________________________________________
VEHICLE #1 EXACT LOCATION ON PROPERTY ___________________________________
________ Year ________ Model ________ Color ______
____________________________________
_______________________________________________________________
VEHICLE #2 EXACT LOCATION ON PROPERTY ___________________________________
________ Year ________ Model ________ Color ______
____________________________________
_______________________________________________________________
FALSE STATEMENTS MADE HEREIN ARE PUNISHABLE AS A CLASS "A" MISDEMEANOR
PURSUANT TO SECTION 210.45 OF THE PENAL LAW OF THE STATE OF NEW YORK.
OWNER/AGENT
__________________________ __________________________ ________
Print Sign Date
NOTARY PUBLIC
__________________________
