Owner'S Application To Restore Rent Form
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1
2New York State
Docket Number:
Division of Housing and Community Renewal
(For DHCR Use Only)
Office of Rent Administration
Web Site:
Owner's Application to Restore Rent
Mailing Address of Tenant:
Mailing Address of Owner/Agent:
Name:
Name:
Number &
Number &
Street:
Apt. No.:
Street:
City,
City,
State, Zip Code:
State, Zip Code:
Telephone
Telephone
Number: (
)
Number: (
)
Subject Building (if different from tenant's mailing address):
Number and Street
Apt. No.
City, State, Zip Code
Instructions:
The following must be attached to your application in order for your application to be processed:
Note: Applications will be rejected if they are not completed and filed correctly.
1.
An original and one (1) copy of this application and supporting documents must be filed at the Division of Housing and Community
Renewal (DHCR) office noted on the reverse side of this form, together with a complete copy of the rent reduction order or order
directing restoration of service. You must date and sign Part B and Part C (if applicable).
2.
If more than one tenant is affected by the order, you must also provide the following:
A) The list of all affected apartments from the rent reduction order and/or order directing restoration of services.
Applications must be filed for all apartments affected by an order.
B) Additional copies of your application, supporting documents, and mailing labels must be provided for each affected tenant.
PART A
(Please check all boxes that apply)
[ ] A. The owner has restored all services for which a rent reduction order and/or order directing restoration of services was issued
on _____/_____/_____, pursuant to docket number ___________________________. Attach a complete copy of the
order.
Clearly describe the restored services, equipment or facilities, the date made or furnished, whether the equipment is new or used
and the cost. Submit receipted bills or other evidence of the expenditure. (If more space is required, attach a separate sheet to this
application.)
[ ] B. The above named tenant of the subject unit agrees and consents to same as above.
(Tenant's Statement of Consent must be signed under Part D)
(SEE REVERSE SIDE)
RTP-19 (5/09)
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