Income Certification Form (Page 3 of 4) in pdf

Income Certification

I (we) hereby certify that the total annual income (the total federal adjusted gross incomes as reported on the New York State income

tax returns) of all persons identified in Items 5 and 6 above, excluding (for rent-stabilized and rent-controlled apartments):

• those persons listed in Item 5 under status "d";

• those persons designated as employees or subtenants in Item 6;

• those persons listed in Item 6 under status "b" and "d"; and

• for rent-controlled apartments only, also excluding those persons listed in Item 5 under status "b," is

(Check one)

in excess of $200,000.00 in each of the two preceding calendar years.

$200,000.00 or less in either of the two preceding calendar years.

Date

Name (printed)

Signature of Tenant

Name (printed)

Date

Return the completed form to the owner, at the address indicated in Part A, Item 1 on page 1 of this form.

Do not return this form to DHCR.

It is not necessary that the statements made in this form be notarized. However, intentionally false statements may subject you to the

penalties provided by law.

Notice to Tenant(s)

By serving you with this form for completion, the owner is asking for information which may result in the elimination of rent control or

rent stabilization protections for your apartment, such as the protections against unlimited rent increases and eviction. The income level

certified to by you may be subject to verification by the New York State Department of Taxation and Finance pursuant to Section

171b of the Tax Law. You are not required to provide any information regarding your income except that which is requested on this form.

You have protections available to you to prevent harassment by the owner.

You must return this completed certification to the owner (not to DHCR) at the address indicated on this form within thirty days after

the owner served you with the form. You should retain a copy of the completed form. Failure to reply may ultimately result in the

deregulation of the subject housing accommodation.

You must keep photocopies of the preprinted mailing labels or the first page of the New York State income tax returns (with social

security numbers and income figures deleted) for each tenant or occupant listed on this form for both tax years 2015 and 2016 for

future submission to DHCR when requested.

Notice to Owner

DHCR shall dismiss an owner's petition for deregulation where the owner cannot prove that the Income Certification Form was served

upon the tenant on or before May first of each calendar year. Owner's may not serve an ICF on any apartment where the tenant is

the recipient of SCRIE or DRIE benefits. The owner is required to serve the Income Certification Form by any of the following

methods:

1) Personal delivery, where accompanied by a copy of the Income Certification Form signed (not initialed) by the tenant upon

receipt; and/or

2) Certified mail where accompanied by a United States Postal Service receipt; and/or

3) Regular first-class mail where accompanied by a United States Postal Service Certificate of Mailing.

It is suggested that the owner retain proof of service, together with a copy of the form served on the tenant.

Quienes deseen más información o asistencia, pueden llamar a la Línea de Información de Alquileres de la DHCR a (718) 739-6400.

11/16)

-3-

RA-93 CF (

Income Certification Form Page 3

Related Articles

Related forms

Related Categories