Scrie - Certification By Scrie Renewal Applicant Without A Renewal Lease - 2011

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NYC DEPARTMENT OF FINANCE
PROGRAM OPERATIONS DIVISION
S C R I E
G
C C E E R R T T I I F F I I C C A A T T I I O O N N B B Y Y S S C C R R I I E E R R E E N N E E W W A A L L A A P P P P L L I I C C A A N N T T
TM
Finance
W W I I T T H H O O U U T T A A R R E E N N E E W W A A L L L L E E A A S S E E
Mail to: NYC Department of Finance, SCRIE Exemption, 59 Maiden Lane, 22nd Floor, New York, NY 10038
Instructions: This form should be submitted by SCRIE Rent Stabilized renewal applicant who is unable to ob-
tain a renewal lease from his/her landlord.
Renewal Leases are required to award an increase in your SCRIE benefits. Please make every effort to obtain and sub-
mit a renewal lease. If you are unsuccessful, please submit this form with proof of tenancy/address. If you meet the el-
igibility requirements, this form will allow you to retain your benefits at the current amount.
SECTION I - APPLICANT INFORMATION
A.
Name: _____________________________________________________________________________
PRINT FIRST NAME
PRINT LAST NAME
Address: ______________________________________________ Apartment No.: _______________
NUMBER AND STREET
City: ____________________________________ State: ___________ Zip Code:_______________
SCRIE Docket # ___________________________ Telephone Number: (____) __________________
SECTION II - REASON FOR FILING FORM
Indicate reason you cannot provide lease with renewal application (check one of the 3 boxes below):
/
/
K
My lease is about to expire/has expired on
and my landlord has not provided
__________
__________
__________
me with a renewal lease.
date
K
My landlord and I have a verbal agreement, and s/he does not provide me a renewal lease.
K
Other. Please explain: ________________________________________________________________
____________________________________________________________________________________
SECTION III - PROOF OF TENANCY/ADDRESS
In lieu of a lease, the Department of Finance requires that you submit proof that you currently reside in the
apartment. Please submit one of the following:
Rent Due statement from this month or previous month.
G
Utility bill in your name from this month or previous month.
G
SECTION IV - CERTIFICATION
I hereby affirm under the penalties imposed by law that the information provided herein is true, correct and
complete.
I understand that by submitting this document, if all other requirements are met, my SCRIE benefits will be re-
newed without an increase.
I acknowledge that I cannot be issued an increase to my SCRIE benefits unless I provide a renewal lease in-
dicating my new and increased rent.
/
/
________________________________
________________________________
________
________
_______
Signature of Tenant
Print Name as Signed at Left
Date
If you have any questions, please call 311.
Visit Finance at nyc.gov/finance
SCRIE Cert Renewal No Lease 3.22.11

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