Income Certification Form (Page 2 of 4) in pdf

5. List the names of all tenants of this housing accommodation. Include all persons whose names are recited as the tenant or co-

tenant on any lease (for rent-stabilized housing accommodations) as well as "statutory tenants" (those without a current lease)

if this is a rent-controlled housing accommodation. In the "status" column, enter: "a" for those tenants who occupy this

housing accommodation as a primary residence on other than a temporary basis or who have sublet this housing accommodation

to another person; "b" for those tenants who occupy it as a non-primary residence; "c" for those tenants who have temporarily

vacated this housing accommodation (other than those listed under "a" above who have sublet the housing accommodation), and

"d" for those tenants who have permanently vacated the housing accommodation. If you entered "c" or "d" for any tenant, enter

the date upon which that tenant vacated the apartment. For each tenant listed, indicate by writing "Yes" or "No" in the space

provided, whether the tenant filed New York State income tax returns for 2015 and 2016. If any tenant did not file a return for

one or both years, give the reason(s) for not filing. (Attach an additional sheet if necessary.)

Status

Vacancy Date

N.Y.S. Income

(a), (b), (c),

for status (c) or (d) Tax Return Filed?

Name of Tenant

or (d)

(mo./day/yr.)

2015

2016

Reason for not filing

___/___/___

List all the names of all other persons who occupy this housing accommodation as a primary residence on other than a temporary

basis as of the date this form was served upon you by the owner, or who occupied it as a primary residence on other than a

temporary basis at any time during the period from January 1, 2015 through the date this form was served upon you by the owner

(include children and other relatives). In the "status" column, enter "a" for such persons who occupy the housing accommodation

as a primary residence on other than a temporary basis as of the date this form was served upon you by the owner; "b" for such

persons who now occupy the apartment as other than a primary residence; "c" for such persons who have temporarily vacated the

housing accommodation, and "d" for such persons who have permanently vacated the housing accommodation. For all persons

whose status you entered as "b," "c," or "d," enter the date such persons ceased maintaining the accommodation as their primary

residence or vacated the accommodation. If any person listed is a child, a bona fide employee of an occupant residing in the

housing accommodation in connection with such employment, or a bona fide subtenant in occupancy pursuant to the provisions of

Section 226-b of the Real Property Law, check the appropriate box. For each person listed (other than a bona fide employee or a

bona fide subtenant), indicate, by writing "Yes" or "No" in the spaces provided, whether such person was required to file New York

State income tax returns for 2015 and 2016 and whether such persons did file such returns.

N.Y.S. Income

Date of Vacancy or

Tax Return

Status

of Change in Use

Required?

Filed?

(a, b, c,

(mo./day/yr.)

Age of

Name Occupant

or d)

for status b, c, or d

Employee

Subtenant

Child

2015

2016

2015

2016

___/___/___

If any occupant listed (other than a bona fide employee or bona fide subtenant) did not file a N.Y.S. income tax return for either or

both years, indicate that occupant's name and explain (attach an additional sheet if necessary): ___________________________

_________________________________________________________________________________________________________

7. List the docket number(s) of all DHCR proceeding(s) involving the subject housing accommodation: ________________________

_________________________________________________________________________________________________________

11/16)

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RA-93 CF (

Income Certification Form Page 2

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