Program Integrity Liens Amount - HRA

Human Resources Administration

Serving New Yorkers with Care & Compassion


Liens Amount Form


Please Complete the Form

* - indicates required fields

Plaintiff Name: *

Type of Lien: *

Final

Updated

Last 4 Digits of Client SSN: *

Date of Birth: *

Settlement Amount:

Date of Incident: *

NYC File Number (if action against NYC):

Settlement Date:

Index Number:

Case Number or CIN:

Specific Injury (E.G., Ankle Fracture): *

Attorney Requesting Lien Represents: *

Defendant

Plaintiff

Firm Name: *

Firm Address: *

Firm City: *

Firm State: *

AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PE
PQ
PR
RI
SA
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT

Firm ZIP Code: *

Attorney Name: *

Attorney Email Address (e.g., test@example.com): *

Attorney Phone: *

Attorney Fax:

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Submit