On September 20, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
Sean A Gadsden,
and
Agnaldo B Gouvea,
Derosa Sports Construction, Inc.,
for Torts - Motor Vehicle
in the District Court of Queens County.
Preview
FILED: QUEENS COUNTY CLERK 01/15/2024 04:21 PM INDEX NO. 719456/2023
NYSCEF DOC. NO. 14 RECEIVED NYSCEF: 01/15/2024
MV-104 (5/22) PAGE 1 of 2 FOLD Î
Ä- HERE
New York State Department of Motor Vehicles
"Za®np°e"N°
( '"! ) REPORT OF MOTOR VEHICLE ACCIDENT
www.dmv.ny.gov
BEFORE COMPLETING THIS FORM, REAO THE INSTRUCTIONSIN SECTION A ON P " O
AÎciÊ A Page Df . RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT
AcdrinniDate DayofWeek Time Numberof Number Number Didpolicemvest .ita II Žcs". Hwnetrf PoliceAgencyorPmrmerS AccdentNmnber
Momb D. Year AM VeNcles injured Killed acý1entatscenc?
od n & ars THuM G¤trPM a I O a Yes a N.
DRIVER OF VEHICLE 1 DVVEHICLE 2 O PEDESTRIAN O BICYCLIST Q OTHER PEDESTRIAN -
DriverLicenseIDNumber Stateof Ucense DriverLicenseIDNumber StateofUcense
2MS ph 59 D NY [ž
DriverName-exactly
asprinte icense(L 1.First,M.I.) asprintedonlicense(Last.First,M.I.)
Name-exactly
G stECséAN A6MA Gouv@ Number . A&NALDO. BRLBfND
Apt Number AddressInclude & Siroas) Api.Number
Q CityorTown State Zip Code Cityor Town State . . ZipCode
ne RIS BuRG FAEl ntil mew Route-Le AA/ osol
DateofBirth Sex Numberof Public DateofBirth
2" Sex Numberof Public
sMgHF,Tw M Wd o el0 ed
asprintedonregistration
Name-exactly DateofBirth Sex asprintedonregistration
Name-exactly Dateof BMh Sex
M° Year Mon D Year
SGAN hJ0tA GADS D&N
Address(includeNumber& 5treef Apt,Number AddressincludeNumber& Street pt.Number
CityorTown State Zip Code Cityor Town State ZipCode
-
PAB It MS73
PlateNumber StateofRe VehicleYear& Make VehicleType Ins.Code PlateNumber Stateof Re . VehicleYear& Make VeNcleType ins.Code
L2A'1524 f?A
Costof PropertyDamage- Vehicle1
Estimated
202.176eb fE7
Estimated
A4 A A1
Costof PropertyDamage- Vehicle2
W .2olrut6V
O 51.001-st500 O $1,501-$2,500 O over 52.500 O S1,001-$1,500 ,--.GI 5t501-52.500 O overS2.500
L1.1 Describedamageto vehicle1 ACCIDENT DIAGRAM:Circleoneof the 9 diagrams(numbred 0-8) if it LeftTum tearEnd' Sideswipe Describedainadeto VEhicle2
O describestheaccident.or drawyourowndiagrambelowin space#9, (samedirection)
Numberthevehicles.Yourvehicleis # 1
LeftTum RightAngle RightTum
RightTum HeadOn Sideswipe
(oppositedirection)
9, 6. B.
Place Where Accident Occurred in New York State:
County Q LOf.f O City O Village O Town of . PerrnamentLandrnark
2
I-
Roadon whichacddent occurred .2
piouteNumterorhiraelName)
at 1) intersectingstreet
Numberor 6treelNama)
t@toute
ON OS
or 2) O E O W of
Feet Mdes Nearesttritersecting
(Milepost, HouteNumberorStreetName)
Howdidthe accidenthappen? Qd" Ch.
& ht (A) .• O
O
8.WhichVeh 9. Posïtion 10. Safety 12. 13. 16.Injury IfDeceased,Enter
NamesofAllPersonsInvolved Occupied in/onVehicle Equip.Used Age Sex A B C Describeinjuries Dateof Death
5 Moso,5aN A I M x ,wts.dnoutrim,t
-e saaves scwAl--co s. a- E / F I I M
-
El I E I
2 - L-
ra | I
IdentifyDamagedProperty VIN
OIberTha9VehicInts)
Nameof Insurance Company Policy
Thal.Issued PolicyForVehids1 Number.
NameandAddressof PolicyPeriod
PolicyHolder From To
If VehiclewasOperatedUnderPermit NameandAddress
(ICC,USDOTor NYSDOT), giveNo. of PermitHolder
If Self-Insured,
give andState
CerlificateNo
Datu PrintNameof Driver &gr'atureofDriver
* A representa9vamay sign for ihe driverIf the driver is unableto sign
tr.auso of injury m cleath,Ifyou are signingas the rirrver'srepresentative, Injury An accident report is not considered complete and filed unless it Is signed.
checkthe box thatdescribeswhy thedrivercannotsign. O Death and if not signed may result in the suspension of your driver's license.
Document Filed Date
January 15, 2024
Case Filing Date
September 20, 2023
Category
Torts - Motor Vehicle
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FILED: QUEENS COUNTY CLERK 01/15/2024 04:21 PM INDEX NO. 719456/2023 NYSCEF DOC. NO. 14 RECEIVED NYSCEF: 01/15/2024 MV-104 (5/22) PAGE 1 of 2 FOLD Î Ä- HERE New York State Department of Motor Vehicles "Za®np°e"N° ( '"! ) REPORT OF MOTOR VEHICLE ACCIDENT www.dmv.ny.gov BEFORE COMPLETING THIS FORM, REAO THE INSTRUCTIONSIN SECTION A ON P " O AÎciÊ A Page Df . RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT AcdrinniDate DayofWeek Time Numberof Number Number Didpolicemvest .ita II Žcs". Hwnetrf PoliceAgencyorPmrmerS AccdentNmnber Momb D. Year AM VeNcles injured Killed acý1entatscenc? od n & ars THuM G¤trPM a I O a Yes a N. DRIVER OF VEHICLE 1 DVVEHICLE 2 O PEDESTRIAN O BICYCLIST Q OTHER PEDESTRIAN - DriverLicenseIDNumber Stateof Ucense DriverLicenseIDNumber StateofUcense 2MS ph 59 D NY [ž DriverName-exactly asprinte icense(L 1.First,M.I.) asprintedonlicense(Last.First,M.I.) Name-exactly G stECséAN A6MA Gouv@ Number . A&NALDO. BRLBfND Apt Number AddressInclude & Siroas) Api.Number Q CityorTown State Zip Code Cityor Town State . . ZipCode ne RIS BuRG FAEl ntil mew Route-Le AA/ osol DateofBirth Sex Numberof Public DateofBirth 2" Sex Numberof Public sMgHF,Tw M Wd o el0 ed asprintedonregistration Name-exactly DateofBirth Sex asprintedonregistration Name-exactly Dateof BMh Sex M° Year Mon D Year SGAN hJ0tA GADS D&N Address(includeNumber& 5treef Apt,Number AddressincludeNumber& Street pt.Number CityorTown State Zip Code Cityor Town State ZipCode - PAB It MS73 PlateNumber StateofRe VehicleYear& Make VehicleType Ins.Code PlateNumber Stateof Re . VehicleYear& Make VeNcleType ins.Code L2A'1524 f?A Costof PropertyDamage- Vehicle1 Estimated 202.176eb fE7 Estimated A4 A A1 Costof PropertyDamage- Vehicle2 W .2olrut6V O 51.001-st500 O $1,501-$2,500 O over 52.500 O S1,001-$1,500 ,--.GI 5t501-52.500 O overS2.500 L1.1 Describedamageto vehicle1 ACCIDENT DIAGRAM:Circleoneof the 9 diagrams(numbred 0-8) if it LeftTum tearEnd' Sideswipe Describedainadeto VEhicle2 O describestheaccident.or drawyourowndiagrambelowin space#9, (samedirection) Numberthevehicles.Yourvehicleis # 1 LeftTum RightAngle RightTum RightTum HeadOn Sideswipe (oppositedirection) 9, 6. B. Place Where Accident Occurred in New York State: County Q LOf.f O City O Village O Town of . PerrnamentLandrnark 2 I- Roadon whichacddent occurred .2 piouteNumterorhiraelName) at 1) intersectingstreet Numberor 6treelNama) t@toute ON OS or 2) O E O W of Feet Mdes Nearesttritersecting (Milepost, HouteNumberorStreetName) Howdidthe accidenthappen? Qd" Ch. & ht (A) .• O O 8.WhichVeh 9. Posïtion 10. Safety 12. 13. 16.Injury IfDeceased,Enter NamesofAllPersonsInvolved Occupied in/onVehicle Equip.Used Age Sex A B C Describeinjuries Dateof Death 5 Moso,5aN A I M x ,wts.dnoutrim,t -e saaves scwAl--co s. a- E / F I I M - El I E I 2 - L- ra | I IdentifyDamagedProperty VIN OIberTha9VehicInts) Nameof Insurance Company Policy Thal.Issued PolicyForVehids1 Number. NameandAddressof PolicyPeriod PolicyHolder From To If VehiclewasOperatedUnderPermit NameandAddress (ICC,USDOTor NYSDOT), giveNo. of PermitHolder If Self-Insured, give andState CerlificateNo Datu PrintNameof Driver &gr'atureofDriver * A representa9vamay sign for ihe driverIf the driver is unableto sign tr.auso of injury m cleath,Ifyou are signingas the rirrver'srepresentative, Injury An accident report is not considered complete and filed unless it Is signed. checkthe box thatdescribeswhy thedrivercannotsign. O Death and if not signed may result in the suspension of your driver's license.