Jnsp. 11 Rev 6/10

Personnel Complaint Work Sheet
Tvoe: Personnel Inv.
Initiated Bv:

ISub Tvoe:

Iincident Date: 5/12/20
I Detail ~ Troop

ICTV: F3659

[8:JC = Citizen □ s = NYSP

I

I Case Number

ID

ID

Incident T ime: 11 :00

AM
Level of lnvestiaation

T

1

ID

I□

Mode Received
1:8:J EMail
In Person
Letter
Survey
Phone
□ Fax
Synopsis of Complaint: Complainant states Tpr. Michael Raap of SP Deerpark failed to properly investigate
a motor vehicle accident.

Subiectfs\ of Comola int
Employee ID #

~

Last Name

First Name

Ml

EOD

Raap

Michael

G

5/10/99

Comolainant lnfonnation fif Member see below\

-Address

Name

Constance Y. Marines
Home Phone- -

Work Phone - -

Member lnfonnation (if comolainanO
Employee ID #

Maiden Name

-

-City & State

Zip Code

Cell Phone

Rank/Name

TZS

Administrative Notification Information - Dates are reauired - Times are desirable
Receiv ing Member

-------

Employee ID #

Rank/Name

Date

Time

Major Gregory Thomas

6/15/20

10:19 AM

Rank/Name of Member at Troop Notified

Date

Time

Capt. Mark Nielson

6/16/20

3:27 PM

Rank/Name of Member Notifying Troop

Date

Time

Major Gregory Thomas

6/15/20

10:19 AM

Date

Time

Troop Notification

Employee ID #

Employee ID #

Division Notification

Employee ID #

Employee ID #

Employee ID #

Rank/Name of Member at Division (or Duty Officer) Notified

Major Gregory Thomas

6/15/20

9:00AM

Rank/Name of Member Reporting Complaint to Division

Date

Time

Capt. Peter Cirigliano II

6/17/20

2:00 PM

Rank/Name of Investigating Member

Date

Time

Sgt. Andre Terry

6/17/20

2:02 PM

Some fields have a built-in Help feature that will work when opened with Word. With the cursor on the field,
you m ay clic k F1 to invoke Help o r c heck t he status bar on t he lower left f or tips on data ent ry.

PROFESSIONAL STANDARDS BUREAU
PERSONNEL COMPLAINT TRACKING
DCN: 2020-0180
CTV: F3668
REGION:SRO
LEVEL: I
TYPE: Personnel Complaint
Subiect/sl: Trooner Michael G. Raan
Investioated bv: Seroeant Andre R. Terrv
Troon or Detail
F
Staff Insnector: Gre•orv Thomas
Date: occurred on 5/12/20
SUBJECT HISTORY REVIEWED? [gi
AUDIO? □
ON PROBATION? □
VIDEO? □
ALLEGATION: Service Comnlaint
SYNOPSIS: On June 13, 2020, complainant contacted PSB-HQ regarding a motor vehicle collision investigated by Trooper Raap,
wherein he failed to obtain pertinent information of an uninvolved, yet potentially contributory tractor trailer.
On May 12, 2020, Trooper Raap responded to a minor PIAA at SR 284 and CR 93, T/Wawayanda. Complainant stated the uninvolved
tractor trailer began to enter her lane, causing her to take evasive action and run of the roadway, striking a culvert. Trooper Raap
interviewed the uninvolved operator, but failed to document any information, which would have allowed the complaint to make a claim
for damages sustained as a result of the collision.
Major James C. Michael, Troop F Commander, determined this Personnel Complaint is Founded, with Tpr Raap violating NYSP
Regulation:
8A2 for Failure to comply with Rules/Regulation/Instructions, specifically:
Article 38J3(a)(l) Investigate all motor vehicle collisions reported to you and determine what action is necessary to perfom1 a

complete investigation.
A/Inspector Gregory Thomas concurs with the findings of Major Michael.

Finding of Investigation: [8l Founded
Recommended Level of Adjudication:
Adjudicated at Troop[8l

D Unfounded D Unsubstantiated 0
D Troop Level 0 Division Level
Date:11/23/2020

Disposition:

Closed by Investigation

Letter of Censure

Date Forwarded to Assistant Deputy Superintendent-Professional Standards Bureau: GST 12/01/2020
: : . - ,
Assistant'Den,ih•.sunerintendent . Profcssfonal:Sfandaids·Btii-eau':- :,;:•:: '•·: ':, ,:\,:Date::.
Comments:

-

Finding of Investigation:

0

Founded

Recommended Level of Adjudication:

,..

D Unfounded D Unsubstantiated D Closed by Investigation
D Troop Level 0 Division Level

Date Forwarded to Denutv Sunerintendent Professional Standards Bureau
·.DenutvSun0i-intendent ··'.•Pro{essioJial'StandaroslBiireau:;:;;;:;;;g;;;;Date,lllllilllliB!,;,'!il,!'.,~'ll'f:~~';;J!iJ' ,,,.
Comments:

D Division Level Recommended
0 Troop Level Recommended
Date Fonvarded to First Denutv Suoerintendent:
'First Oenutv Snnerintendent,. · ;·•:; . i"":.:;\0:
-:• "
Direction:

-:~__ -y . "'~'-- '

-c: :,•, , :·_·:"":· '!;;f

D Troop Level-Return to Chieflnspector
D Division Level - Forn-ard to Division Counsel
Date Forwarded to Counsel or the Chieflnsnector:
D Troop Level
Rank/Name of Member Notified
Date Notified:

.

Notified by Whom:

,~{.)?, :lr·

\4- -,~ .•

.

-

....," ;,_;·

..\Y ·:· .!\

4

w

State
Police

RK
~TE

KEITH M. CORLETT
Superintendent

ANDREW M. CUOMO
Governor

November 23, 2020
Trooper Michael G. Raap
New York State Police
Deerpark, NY
RE: DCN 20200180
LETTER OF CENSURE
Dear Trooper Raap:
On May 12, 2020 at approximately 11 :00AM, you responded to a one-car motor vehicle
accident at the intersection of State Route 208 and County Route 93 in the Town of Wawayanda. The
sole occupant of the vehicle later alleged that you failed to adequately investigate the accident when you
did not obtain the identity of the male operator of a tractor trailer who she alleged had caused her to crash
her car. Subsequent investigation determined that you also did not obtain the registration infonnation of
the tractor trailer, information which could have been pertinent to the accident investigation. In failing to
complete an adequate motor vehicle collision investigation and determine what action was necessary to
perfom1 a complete investigation, you acted in violation of Regulation 8A2.
On November 23, 2020, you appeared before me, executed a waiver and requested that I
adjudicate the discipline in this matter.
Accordingly, it is my decision that you receive a letter of censure for your actions. I trust
that you will not allow this to happen again.

a~::~c::~
~~::~:nes
C. Michael
Troop Commander
Troop F

Building 22, 1220 Washington Avenue, Albany, NY 12226

I www.troopers.ny.gov

Administrative Investigation Report

PC#

20200180

.RCN#

SJS#

9584605

Date:

'

05/12/2020

Incident Review

level 1 PC

lnJurynllness to Person Prior to
Custody

lnjurynllness 10 Person Being Taken
into Custody

Injury/Illness to Person While In
Custody

Division Vehlcle PDAA

Division Vehicle PIAA

Damage/Loss of Division Property

1

1

p age
..

New York Slate Police

INSP-8 (Rev 12/161

□
□
□

Member Receivin ·Initial Com · laint

Reported By:

Telephone

Date Occurre?:

05/12/2020

County:

Time Occurred: 1,1 :00 am

Date Reported:

Shield

F261 2259

Sergeant

Anderson, Erik, P

PlaceofOccurrence:

TZS

Rank

Name (Last, First, Ml)

06/13/2020

Time Reported:

3:00 pm

State Route 284 and County Route 93 T/Wawayanda
crrN: T/Wawayanda

Orange

C1V Code:

F3668

Synopsis: Trooper Michael Raap investigated a one car motor vehicle accident with injuries at the Intersection of State Route 284 and County
Roule 93 in the T/Wawayanda.
-:.

,

Name (Last, First. Ml)

..:~-~•:,. ;. \ ,

,.:-. ~

;.,~· .;-:

-

.

,.· -1

:.~;~...:: .

,

Trooper

Raap, Michael, G

TZS

Shleld

F262

2989

Race

White

. d Person·#t - COMPlAINANT·
Sex

Race

F

White

Employee ID#

Rank

TZS

Duty Time Lost

Shield

If Member:

ARS #

hrs

Nature:
How Occurred:

~

a,
C

=
..
0

~
::1

Name of Hospital/EMS:
Treated by:
Treatm~nt Refusal Witnessed by:

:St------ -- - - -- -- - - - -- - - -- - - - -- - -- - - --------------1
If Prisoner- Charges:
Use of Force:

Type of Force:

1)

2)

Page

New York State Police

. INSP·8 (Rev 11/16)

Administrative Investigation Report

PC#

20200180

SJS#

9584605

.

2

;.~~

•··

.~·

'

'f'X :

05/12/2020

Date:

ex

Race

F

White

ex

Race

White

F

Race

Sex

··•

DOB

Make

Model

Year

Mileage

VAN#

Reg. State

Color

Reg. #

,

Division Vehicles:
,e ':

-,

Make

Reg. State

Color

Model

Year

Mileage

VAN#

Sex

Race

DOB

Operator (Lasl. First, Ml)

14,·.

Reg.#

. .·<

;;

•

Division Vehicles:

..

.. ~:..

NIA
Type

Rea:wn for Damage/Loss

Make

Model

Property Description

Reg.#

VAN#

CaVGa

Year

Serial#

Property Value

Damage Description

$
DOB

Owner (last, First. Ml)

Address

City

Sex

Raco

State

Zip

Phone

.

...

,.

PC#

Person Interviewed Supplemental

3

Page

New York State Police

INSP-SPI (Rev 12/16)

20200180

'
Date:

SJS#

.. .: ~·

:; .:

,

05/12/2020

.Per
Name (Last. First. Ml)

Hanak, Robert
Address

DOB

State

City

Address

Person Interviewed # .

Sex

Race

PhOne

Zip

'
DOB

Name (Last. First, Ml)

Phone

City

Address

Race

DOB

Name (Last, First, Ml)

State

City

Address

City

Sex

Phone

Zip

DOB

Address

Sex

Race

Sex

Race

State

Phone

Zip

- Interviewed #
DOB

Name (Last, First Ml)

·\ ·:i .•.

Phone

Zip

.·

DOB

Name (Last, First. Ml)

Address

State

City

Address

Sex

Race

City

Sex

Race

State

Zip

Phone

INSP-8 (Rev 11/16)

4

New York State Police
PC#

20200180

SJS#

9584605

Administrative Investigation Report

La_st Name of Person(s) Submitting Memo(s):
Memo(s)

[l]

Raap

Last Name Of Pers~n(s) Signing Deposition(s) and/or Statement(s):
Depositions
and/or
Statements

[l]

Marines

Title and Last Name

Medical
Deposition(s)

AMS Message
IJ Portal Message
GENL-34D
Photo Record
GENL-89 Use of
Chemical A ent
GENL-90 Use of
Taser X26/X26P
GENL-91 Vehicle
Pursuit Report
MV-104A Police
Accident Report
Non-SP
Collision/Incident
Report (TRACS)
Audio ReCording
Video Recording
GENL-81
Medical Reiease
GENL-81E
Medical Release
GENL-81M
Medical Release

Other Enclosures

Eiy!S Service or Medical Facility

□

□
□
□
□
□
□
[l]
□
□
□
□
□

# Enclosed:·

Transcript enclosed:

Eilter Source:

# Enclosed:

Transcript encl_osed:

Enter Source:

.Last Name(s):

Records Enclosed:

Yes

Records Enclosed:

Yes

Records Enclosed:

Yes

Employee(s) Last Name:

Member(s) Last Name:

□
[l]

Describe~

Accident Exchange Information Form

□
□
□

No

No

No

□
□
□

Administrative Investigation Report

Name

PC#

20200180

SJS#

9584605

.-z

~.i

Date:

..

'

··:;,.

05/12/2020
TZS

Rank

Andre R Terry

5

Page

New York Stale Police

INSP-8 (Rev 11/16)

F261

Sergeant
Date

Signature

10/27/2020
Name

Thomas Brozycki

,.

Rank

TZS

Lieutenant

F200

Date

10/27/2020
To: Troop Commander

1 concur with the findings of this Investigation:
Date:

Yes

ll, a/ 2.0

From:

Yes

~No

D

Signature:

riate status:

□

Non-Preventable

Preventable

Unfounded

Founded

D

If. Fou.nded,. complete •the follovviog: ~·
Date:

Rule 3 Waiver Form attached

Unsubstantiated

D

□

Closed by Investigation

D

Copy of Memorandum of Disposition to Member Attached

Disposition imposed under Rule 3:

No Action Warranted

□

Letter of Censure

□

Intra - Troop Transfer

□

Probation
#of days:

D

Loss of A.L. Days

#of days:

□

INSP-BN (Rev 11/16)

New York State Police

Administrative Investigation Report
Narrative

Page 1 of 1

PC#

20200180

SJS#

9584605

Date:

10/27/2020

On 05/12/2020 at approximately 11 :00 a.m. Trooper MICHAEL RAAP responded to a one car
motor vehicle accident with injuries at the intersection of State Route 284 and County Route 93 in the
Town of Wawayanda. CONSTANCE MARINES was the operator and the sole occupant of a 2018
Ford bearing New York registration JRM3813. (Reference Accident Report #SP2F20BTS9GH).
On 07/13/2020, I interviewed MARINES and secured a deposition from her which states in sum
and substance that Trooper RAAP failed to adequately investigate a motor vehicle accident by failing
to obtain the identity of the male operator of the tractor trailer who she alleges caused her to crash
her vehicle.
On 08/03/2020, I interviewed Trooper RAAP, who stated he investigated the accident involving
MARINES. Trooper RAAP stated he interviewed MARINES as well_ as the male operator of the tractor
trailer. Trooper RAAP stated he also interviewed ROBIN HANAK, who was at the scene but did not
witness the accident. Trooper RAAP stated he did not obtain the identity of the male operator of the
tractor trailer nor did he obtain the registration of the tractor trailer.
On 10/21/2020, I interviewed ROBIN HANAK, who stated she was at the accident scene to comfort
her friend, MARINES, but she did not witness the accident and did not know the identity of the male
operator of the tractor trailer. ROBIN HANAK declined to provide a deposition.
On 10/27/2020, I interviewed ROBERT HANAK of Grand Prix Auto, who responded to the accident
scene and towed MARINES'S vehicle to his shop. ROBERT HANAK stated he did not know the
identity of the male operator of the tractor trailer. ROBERT HANAK declined to provide a deposition.
Investigation into this matter revealed that Trooper RAAP failed to obtain the identity of the male
operator of the tractor trailer as well as the vehicle's registration, which would have been pertinent to
the accident investigation.
The complaint is founded in that Trooper Raap violated Regulation 8A2, failure to comply with
instructions, specifically Article 38J3 (a)(1) of the Members Manual which states, Members should
investigate all motor vehicle collisions reported and determine what action is necessary to perform a
complete investigation.

--..,

J

NEW YORK STATE POLICE

MEMORANDUM
Troop F Station Deerpark
Date
To:

Majo.r James C. Michae~Commander

From:

Trooper Michael G. R ~ -

Subject:

DISCIPLINARY ACTION

November 10, 2020

Thereby reques_t to have the above-captioned investigation adjudicated by the
Troop Commander pursuant to Rule 3, Disciplinary Action, of the New York State Police
Manual.
'

•): waive the following:
The right to have this matter disposed of by the Superintendent or by a
formal hearing.

2.

,_.

Any right to appeal the Troop Commander's adjudication, which may be a
determination of unfounded or, upon a finding of guilt, the imposition of
the following penalties:

I.

A letter of censure and/or

11.

An intra-troop transfer and/or

111.

A fine to be expressed in the loss of no more than five vacation
days to be worked by me with no additional compensation or
overtime.

f-1

Gent 7

NEW YORK STATE POLICE

MEMORANDUM
Troop

F Station SP Deerpark

Date._ _ _ _ _""A,.,,u,.g.,,,us"'t,._,3«·-=2""02"'0"'----

To:

Major JAMES C. MICHAEL, Troop F, Troop Commander

From:

Trooper MICHAEL RAAP (.J3)
I
I

.

V

Subjei;t:., . ·. PERSONNEL COMPLAINT

'1-was advised ofmy rights to representation pursuant to Article 16.2 of the
contract by Sergeant ANDRE TERRY. I provide the following account:
0c•·.On May 12, 2020 at I lam I responded to a I car accident (SP2F20BTS9GH) at
.,the ST:284 MiCR 93 intersection in the Town of Wawayanda. Upon arrival at the scene, I
observ~d <t 7of 8'Ford in a culvert in a field on the western shoulder of ST 284. The operator of
the vehicJe,,C_ONSTANCE MARINES, was sitting on the northern shoulder of CR 93 along with
. _a fem~le
spoke to MARINES who stated she was driving northbound on ST 284. She
· · · obseri'.ed tract\)r trailer facing west at the stop sign on CR 93 at the ST 284 intersection.
MARINES stated that the tractor trailer began to proceed west on CR 93 into the intersection of
ST 284. She then swerved to the left to avoid striking the uninvolved tractor trailer. She then
.drove off the 'N!!Stern shoulder of ST 284 striking a culvert in the field.
·;c<fi:hen spoke to MARINE's female friend, ROBIN HANAK, who stated she was
assisting MAR.n:JES with a chest injury suffered from the accident. She stated she did not
observe the accident..
c: . ·· ~(fJhen located the tractor trailer parked on CR 93 just prior to the ST 284 .
intersection. I 'tiiterviewed the male operator who stated in sum and substance that he was driving
westbound ori CR 93 and stopped at the stop sign at the intersection of ST 284. He then began to
slowl)'proceed forward but did not enter the intersection (the stop sign and white stop line are
., _
. set back acouple of feet from the intersection). 'He stated he stopped when he observed the 2018
:--~J:!i¼;[/·.:, Ford. He th~n-dliserved that same vehicle drive off the western shoulder of ST 284 and into the
:,,.
field ...(didi~t'"ohtain the operator's name, date of birth, address, or telephone number.
i,,':':?f:
(':~-.. ; ·:·.0..';:t:.Qrand
Prix auto then responded and removed the 2018 Ford from the field .
. ,...:.~,?:'!j,, F ;;· ,•·· ---•- ...

fi:iln4;;:l

·a

;;:'.'}:.~~:\i~~

PAGE 1

SUPPORTING DEPOSITION (CPL §100.20)

OF 2

NEW YORK STATE POLICE
THE PEOPLE OF THE STATE OF NEW YORK
--vs.

Defendant(s)

LOCATIJ)N Of DEPOSITION:

INCIDENT LOCATION:

COUNTY OF

ORANGE

COUNTY OF

or

TOWN

Time Started

07/13/2020

ORANGE

- -----------

TOWN

WAWAYANDA

II

I

Date

On

STATE OF NEW YORK

COURT

STATE OF NEW YORK LOCAL CRIMINAL

of

GREENVILLE

I I

at ._0_B:_41__P_M_ _____,

Fun Name:

I,

CONSTANCE Y MARINES

State The Following:

ON 07/13120 I WENT TO THE STATE POLICE BARRACKS LOCATED ON US HfGHWAY 6 IN THE TOWN OF
GREENVILLE TO MEET WITH SERGEANT ANDRE TERRY REGARDING A COMPLAINT I MADE WITH THE NEW YORK
STATE POLICE. ON 05/12/20AT APPROXIMATELY 11:00AM I WAS TRAVELING ON STATE ROUTE 284 IN THE
TOWN OF WAWAYANDA OPERATING MY 2018 FORD EDGE BEARING NEW YORK REGISTRATION JRM3813. I WAS
APPROACHING THE INTERSECTION OF STATE ROUTE 284 AND COUNTY ROUTE 93 WHEN f OBSERVED A
TRACTOR TRAILER ON COUNTY ROUTE 93 STOPPED AT THE STOP SIGN. THE TRACTOR TRAILER THEN
PROCEEDED ACROSS THE INTERSECTION AND FAILED TO YIELD THE RIGHT AWAY TO MY VEHICLE. I TOOK
EVASIVE ACTION TO AVOID FROM COLLIDING WITH THE TRACTOR TRAILER AND SUBSEQUENTLY LOST
CONTROL OF MY VEHICLE, WENT OFF THE ROADWAY AND STRUCK A CULVERT I WAS ABLE TO EXIT MY
VEHICLE AND SAW THE DRIVER OF THE TRACTOR TRAILER RUNNING TOWARDS ME. HE WAS A WHITE MALE IN
HIS EARLY 40s BROWN HAIR APPROX 5'10" AND WEIGHED APPROX 210 POUNDS. THE MALE WAS VIS/BLY
SHAKEN UP AND HE ASKED ME fF I WAS OK. I THEN ASKED THE MALE WHY DID HE PULL OUT IN FRONT OF ME
AND HE STATED THAT HE DID NOT SEE ME AND HE APOLOGIZED TO ME. TROOPER MICHAEL RAAP OF THE
STA TE POLICE ARRIVED ON SCENE TO INVESTIGATE THE ACCIDENT. TROOPER RAAP OBTAINED PERTINENT
INFORMATION FROM ME FOR THE ACCIDENT REPORT AND ADVISED ME THAT HE WAS GOING TO SPEAK WITH
THE DRIVER OF THE TRACTOR TRAILER. WHEN TROOPER RAAP CAME BACK TO ME, HE PROVIDED ME WITH AN
ACCIDENT EXCHANGE FORM HAVING ACCIDENT REPORT#

~
(Penal Law §210.45)

In a written instrument, any person who knowingly makes a fa lse statem.ent which such person does not believe to be true has
committed a crime under the laws of the state of New York punishable as a Class A Misdemeanor.
Affirmed under penalty of perjury
TH

this

---'1""-3_ _ dayof

JULY

2020

-OR(WtTNESSl

• Subscribed and Sworn to before me
this

day of

• This foon need be sworn to only When specificaCy rec;ulred by lhe court

•

S ~-t:? &D ,z'F rr11nr
(NAME 01' PERSON TAKING DEPOSITION)

Time Ended

07/13/2020

09:25 PM

£- '2.

PAGE 2

SUPPORTING DEPOSITION (CPL §100.20)

OF 2

NEW YORK STATE POLICE
State The Following:

SP2F20BTS9GH WHICH HAD MY INFORMATION ONLY ON IT. I SUBSEQUENTLY CONTACTED MY INSURANCE
COMPANY TO NOTIFY THEM OF THE ACCIDENT I WAS INVOLVED IN ON 05/12120. MY INSURANCE COMPANY
INQUIRED ABOUT THE INFORMATION OF THE OTHER DRIVER WHICH I DID NOT HA VE AT THE TIME. I CALLED
THE STATE POLICE BARRACKS IN MIDDLETOWN AND WAS TOLD THE OTHER DRIVER'S INFORMATION SHOULD
BE ON THE ACCIDENT REPORT. WHEN I RECEIVED ACCIDENT REPORT# SP2F20BTS9GH, TO MY SURPRISE I DID
NOT SEE THE OTHER DRIVER'S JNFORMA TION ANYWHERE ON THE ACCIDENT REPORT. I CALLED TROOPER
RAAP JMMEDIATEL Y AND ASKED HIM WHY ISN'T THE OTHER DRIVER'S JNFORMA TION ON THE ACCIDENT
REPORT. TROOPER RAAP ADVISED ME THAT SINCE I DID NOT MAKE CONTACT WITH THE OTHER VEHICLE
THERE WAS NO NEED FOR THE OTHER DRIVER'S OR VEHICLE'S INFORMATION TO BE IN THE ACCIDENT
REPORT. I ADVISED TROOPER RAAP THAT THERE WAS A FEMALE SUBJECT WHO WAS AT THE ACCIDENT
SCENE WHO STATED THAT THE TRACTOR TRAILER WAS LEFT IN THE INTERSECT/ON OF STATE ROUTE 284 AND
COUNTY ROUTE 93. TROOPER RAAP ADVISED ME THAT THE FEMALE SUBJECT DID NOT WITNESS THE
ACCIDENT./ IMMEDIATELY ADVISED TROOPER RAAP THAT I WANTED TO SPEAK WITH A SUPERVISOR FROM
THE STA TE POLICE. I SPOKE TO SERGEANT ERIK ANDERSON OF THE STA TE POLICE AND SUBSEQUENTLY
CONTACTED THE STATE POLICE IN ALBANY NY TO MAKE A FORMAL COMPLAINT.

Notice
(Penal Law §210.45)

In a written instrument, ~ny person who knowingly makes a false statement which such person does not believe .to be true has
committed a crime under the laws of the state of New York punishable as a Class A Misdemeanor.

Affirmed under penalty of pe~ury
TH

this

~13~_ _ day of

JULY

2020

-OR(WITNESS)

• Subscribed and Sworn to before me
this

----

day of

Time Ended

.['G' 4N.1e-1; -r'£K"'--f

----

• This form need be sworn to only when specifically required by the court

(NAME OF PERSON TAKING DEPOSITION)

07/13/2020

09:25 PM

Page 1

of 2

New Yoli< Stale Department of Motor Vehicles

Pages

POLICE ACCIDENT REPORT

Local Codes

95846P5

SP2F20BTS9GH

□

Military Time

1-A
..,ca,c);;a:,-;~,,;Da=te.,-- oa=y,--,--""Year,.,..,.----t Day of Week

5

2020

12

·MV-104A (6/04)

AMENDED REPORT

TUESDAY

11 :00

~~t ~n~e~~g~:d_at_ s_~n~ •
Accident Reconstructed

No. of

Vehlcles
1

D Left Seen
D

0

Slate of Lie.

NY

Circle the diagram below thal describes the ac:c:ident,
diagram in space #9. Number the vehicles.

or draw your own

L BO)( 1 - Point of Impact
E Bo)( 2 • Mast Damage
Enter up to three
,.........,3,-1----4+-""""s""'

mote damage codes

ACCIDENT DIAGRAM

14

Vehicle By; GRAND . PRIX
Towed To; GRAND PRIX

See the last page of the MV-104A for t he

accident diagram.

VEHICLE DAMAGE CODING:
1-13 SEE DIAGRAM ON RIGHT.

9.

14, UNDl!RCARRIAGE 17. DEMOLISHED
16. TRAILER
18. NO DAMAGE
1G. OVERTURNED
19. OTHER .

Reference Marker

Coordinates (if available)
Latilude/NOfthing

2 1 8 : 4 •
- - - - - - - _4_5_8_0_0_8_9_ _ __

1---~~-~----, Longitude/Easting
542331)

.

Cost of repairs to any one vehicle will be more than $1000.

D Unknown/Unable to determine

II

~ Yes

O No

Place Where Accident Occurred:
County

□ City

ORANGE

Road on which accident oc:a,rred

ROUTE

~ Town

ROAD

93

""M""I"'-N-"I-"'
S-"'
I ""-N""K_ _ _ __

(Route Niinber or Street Name)

or2)

-~,e~et-

of

..:..:.==..=..=c.......::....::..;:__ _ _ _ _ _ ___,,(R""c
.,..,ut"'e'"'Nlm
="'t>e.,..,r"'Ol"'S"'uee=1""N"'am=e),----

COUNTY

al 1) intersecting street

O Village

284

~

Accident Oesciiplion/Oflicer's notes

V-1 N/B ON ST 284. UNINVOLVED TRACTOR TRAILER STOPPED AT STOP SIGN ON CR 93 AT INTERS;:CTIO~ WITH
ST 284. OP V-1 STATES THAT THE UNINVOLVED VEHICLE BEGAN TO PROCEED WEST INTO THE INTERSECT.ION . OP
V- 1 SWERVED TO AVOID THE UNINVOLVED VEHICLE AND DRIVES OFF THE WESTERN SHOULDER OF ST 284 . V-1
STRIKES A CULVERT .

I
N
V

b

L
V ~2i'='=~'B'!:'::'t'"-~---~~~

E

Troop/Zone Sector

D i,;.;.;.;;;.;;.;.:;.;.;=,;;_-- - ----'u...----":.....:::.;._;~L.:....L......,
Print Name in

Full

MICfil.\EL G RMP

2989

13,508

F2

62

TERRY, ANDRE

5/12/2020
23:17

Page 2

of

2

New York State Department of Motor Vehicles

Pages

POLICE ACCIDENT REPORT

Local Codes

9584605
SP2F20BTS9GH

0

AMENDED REPORT

FAescd;,i!c~~,.::,,0~•71•r--so"',,,-r--cycc.,,,-,--, Day of Week
5

12

2020

TUESDAY

Military Time

11: 00

MV-104A (6/04)
No. of
Vehicles

l

No. Injured No. Killed

l

0

Not Investigated at Scene

A~id;nt Re-~n;t~~t;d -

O Left Scene Police Photos
0 0 Yes ~ No

- -□

.ACCIDENT INFORMATION EXCHANGE FORM
NY State Law requires lhat any accident resulling in a fatality, injury or damage to property of any person (including damage to your vehicle) or entity over
$1000 be reported by YOU to the Department of Motor Vehicles (OMV) within 10 days alter an accident Failure to report an accident or failure to give correct
information is a misdemeanor and may result in the suspension/revocation of your driver's license (or operating priviledge in NYS) and all vehicle certifications
or registrations.

Report your Accident to DMV on OMV form MV-104 (Ra port of Motor Vehicle Accident). Police Accident Reports (DMV fo~m MV-104A) DO NOT
satisfy YOUR clvillan reporting requirement.

Accident Report#

I

Local Codes

Date

511212020

9584605

SP2F20BTS9GH

Police Agency

I

Time

# ofVeh.

Town, City, Road Name

11:00AM

1

MINISINK, TOWN OF· 3659

=er's Name/Badge 10#
MICHAEL

SP DEERPARK - 13508

VEHICLE #

ROUTE284

G

2989

001

Operator's Name
CONSTANCE

y
Vehicle Year and Make

License Plate# and State

2018

JRM3813

FORD

NY

Vehicle Owner
SUBN

CONSTANCE

MARINES

639 - GEICO GEN INS CO

Vehicle Towed By

Vehicle Towed To

GRAND PRIX

GRANO PRIX

Miscellaneous Notes

Please wait 14 days before contacting OMV to request a copy of your accident report.
If you want to purchase a copy of the police accident report, form MV-104A,

complete DMV's "REQUEST FOR COPY OF ACCIDENT REPORT" fem, MV-198C and send it lo DMV.
The form and instructions are available at

www.dmv.ny.gov

or at your local DMV office.

To obtain a blank civilian Accident Report (Form MV-104),
visit the OMV office nearest you
or
access forms online at www.dmv.ny.gov

y