Scrie - Senior Citizen Rent Increase Exemption Initial Application Form

SCRIE

NYC DEPARTMENT OF FINANCE

PROGRAM OPERATIONS DIVISION

FOR OFFICE USE ONLY

SENIOR CITIZEN RENT INCREASE EXEMPTION

INITIAL APPLICATION

Finance

Please complete this form in full and mail it back with all required documents to:

NYC Department of Finance - SCRIE Unit, 59 Maiden Lane, 22nd Floor, New York, NY 10038

SECTION 1 - ELIGIBILITY REQUIREMENTS

To qualify for the Senior Citizen Rent Increase Exemption, you must:

Be at least 62 years old

Be named on the lease or rent order or have been granted succession rights to the apartment and rent an apartment that is rent

controlled, rent stabilized or hotel stabilized.

Have a total household income of $50,000 or less after allowable deductions*

Pay more than one-third of the household monthly income for rent.

*Allowable deductions are Federal, State, Local, Medicare, and Social Security taxes paid. Tenants who live in private homes, a New

York City Housing Authority development and/or receive Section 8 rental subsidies do not quality for SCRIE benefits. Tenants who live

in Mitchell Lama housing must apply for SCRIE with the NYC Department of Housing Preservation and Development.

SECTION 2 - APPLICANT INFORMATION

1. Name of

Tenant: a. __________________________________________

b. _____________________________________________

FIRST NAME

LAST NAME

2. Address: _________________ 3. _____________________________________________________ 4. Apt. #: ___________

NUMBER

STREET NAME

Zip

5. City: _____________________________ 6. Code: _______________

7. Telephone (_____)__________________________

8. Address: __________________________________________________ 9. Date of Birth: ______________________________

10. Indicate total number of rooms and windows: Rooms ______

Windows______

11. Check one indicating your apartment type:

Rent Stabilized

Rent Controlled

Rent Regulated Room or Hotel

12. Check all that applies to your rent increase:

1-yr renewal lease

2-yr renewal lease

Fuel

Building Improvement (MCI)

Maximum Collectible Rent (MCR)

Other: _________________________

13. Have you ever applied for SCRIE before?

Yes

If “Yes”, enter the Docket Number: ______________________

SECTION 3 - TENANT REPRESENTATIVE

You can have copies of your SCRIE notices sent to another person (in addition to you). To select a representative, please complete the following:

1. Name of

2. Email

Representative: _______________________________________________

Address:________________________________

3. Address: _________________ 4. _____________________________________________________ 5. Apt. #: ___________

Zip

NUMBER

STREET NAME

6. City: _____________________________ 7. Code: _______________

8. Telephone (_____)__________________________

SECTION 4 - HOUSEHOLD MEMBERS AND INCOME

HOUSEHOLD MEMBERS: Include yourself and all co-tenant(s) and their income for the calendar year prior to this application.

BOARDERS:

Indicate all boarders and include the amount of rent they pay to you. Family members are not considered boarders.

HOUSEHOLD

SOCIAL SECURITY

PENSION

WAGES AND

INTEREST AND

ALL OTHER INCOME

MEMBER

BOARDER

ANNUITY

IRA

UNEMPLOYMENT

DIVIDENDS

SSA

SSI

SSD

For ex.: Boarder, Public Assistance

SELF

SSN

NAME

DATE OF BIRTH

RELATIONSHIP TO YOU

SSN

NAME

DATE OF BIRTH

RELATIONSHIP TO YOU

SSN

If there are more than 3 household members, please provide information on a separate sheet.

0603151F24

SCRIE Initial Application - Rev. 06.03.2015

Scrie - Senior Citizen Rent Increase Exemption Initial Application Form - 2015

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