Disability Rent Increase Exemption Renewal/recertification Form

DRIE

NYC DEPARTMENT OF FINANCE

PAYMENT OPERATIONS DIVISION

DISABILITY RENT INCREASE EXEMPTION

RENEWAL/RECERTIFICATION

F I N A N C E

NEW

YORK

THE CITY OF NEW YORK

DEPARTMENT OF FINANCE

n y c . g o v / f i n a n c e

Mail to: NYC Department of Finance, Attn: DRIE, 59 Maiden Lane, 19th Floor, New York, NY 10038

Instructions: Use this form if you are presently receiving a DRIE benefit and are recertifying your eligibility status and renewing your application

for the DRIE benefit. The Department of Finance is required to recertify your eligibility for DRIE benefits every two years or at the end of each lease

renewal, whichever occurs first. Please forward the completed, signed application and a copy of your most recent lease to the address above.

SECTION I - APPLICANT INFORMATION

1. Name of Applicant

with a Disability: a. ____________________________________ b. _________________________________________

FIRST NAME

LAST NAME

2. Address: ______________ 3. _______________________________________________ 4. Apt. #: ______________

NUMBER

STREET NAME

5. Borough: __________________________________________________

6. Zip Code: ___________________________

7. Daytime Phone Number: (____) ____________________ 8. Email Address: ___________________________________

9. DRIE Application #: ________________________________

10. Current Rent: __________________ Start Date: _______________________ End Date: ________________________

11. New Rent: ____________________ Start Date: ______________________ End Date: ________________________

SECTION II - ELIGIBILITY INFORMATION

12. How many people reside in the household? ______________________

13. How many people in the household receive income of any kind (work, benefits, etc.)? ____________________________

14. Please indicate the total/aggregate household income for the previous year: $ __________________________________

(Include income for all household members)

15. Are you receiving any of the following benefits? (Check all that apply)

Social Security Income (SSI),

Social Security Disability Insurance (SSDI),

Veteran Disability Pension/Compensation

Disability-related Medicaid?

16. Do you or any other member of your household receive a Senior Citizen Rent Increase Exemption (SCRIE)?

Yes

17. Do you receive Section-8 or any other federal housing subsidy?

Yes

SECTION III - CERTIFICATION

I certify that all information contained in this application is true and correct to the best of my knowledge and belief. I also certify that I contin-

ue to meet the DRIE eligibility criteria. I understand that willful making of any false statement of material fact herein will subject me to the pro-

visions of law relevant to the making and filing of false instruments and will render this application null and void.

____________________________________________________________ ______________________________________

Signature of Applicant with a Disability

Date

____________________________________________________________ ______________________________________

Signature of Preparer (If other than applicant)

Date

Would you like a copy of the DRIE Renewal/Recertification sent to the preparer?

Yes

(If “YES,” provide the preparerʼs name and mailing address, daytime phone, and/or fax number below.)

Name of Preparer: ________________________________________ ___________________________________________