Scrie - Senior Citizen Rent Increase Exemption Initial Application Form

Initial Application for Senior Citizen Rent Increase Exemption

Page 2

SECTION 5 - CERTIFICATION

I hereby affirm under penalties provided by law that I currently reside at this address and have examined this

application and the accompanying documents, and, to the best of my knowledge and belief, the information

provided herein is true, correct and complete.

I understand and agree that if I fail to disclose all household income, including income of tenants (family or

non-family) or any changes to the number of household residents, I may be held responsible to repay the City

the full amount of any SCRIE benefits received improperly plus any interest charges.

I authorize the release of my information to other agencies for the purpose of determining my eligibility for

other entitlements or benefits. I authorize the Department of Finance to review my state and federal income

tax returns to verify my income.

__________________________________________________

_______________________________________________

_________________________________

SIGNATURE OF TENANT

PRINT NAME

DATE

The Federal Privacy Act of 1974, as amended, requires agencies requesting Social Security Numbers to inform individuals from whom they

seek this information as to whether compliance with the request is voluntary or mandatory, why the request is being made and how the infor-

mation will be used. The disclosure of Social Security Numbers for applicants and income-earning occupants is mandatory and is required

by section 11-102.1 of the Administrative Code of the City of New York. Such numbers disclosed on any reports or returns are requested for

tax administration purposes and will be used to facilitate the processing of reports and to establish and maintain a uniform system for iden-

tifying taxpayers who are or may be subject to taxes administered and collected by the Department of Finance. Such numbers may also be

disclosed as part of information contained in the taxpayer’s return to another department, person, agency or entity as may be required by

law, or if the applicant or income-earning occupants gives written authorization to the Department of Finance.

STOP! Final Checklist Before You Mail!

Did you complete all questions on the application?

Did you sign and date the application?

Did you include proof of age with one of the following items: birth certificate, US passport, driver’s license,

or other government-issued identification with date of birth?

For Rent Stabilized Apartments: Did you include a copy of your prior and current lease signed by both you

and your landlord? Please note: The lease must clearly state terms of either a one- or a two-year lease.

For Rent Controlled Apartments: Did you include a copy of the Notice of Maximum Collectible Rent (MCR Form

No. RN-26) and the Certification of Fuel Cost Adjustment (Form No. RA33.10) for the prior and current year?

For Rent Regulated Rooms and Hotels: Did you include a copy of a rent increase letter signed by your land-

lord and a copy of the DHCR Rent History or DHCR apartment registration?

For Building Improvements (Major Capital Improvement): Did you include a copy of the building improve-

ment (MCI) increase? Please note: Rent increases for new appliances (stove, refrigerator, etc.) are not cov-

ered by SCRIE.

Did you include proof of income for all household members including yourself and co-tenants for the calen-

dar year prior to the application? Proof of income includes, but is not limited to:

Income tax returns (if filed)

1099/W2 statement

Social security benefit statement (SSA/SSI/SSD)

Public assistance budget statement

IRA/Annuity statement including earnings

Student status letter for any non-working students

statement

living in your household

Pension statement

Signed letter from friend/family stating amount of

Signed letter from boarder stating rental payments

monetary assistance

GENERAL INFORMATION AND ASSISTANCE

If you need help or have questions please contact 311 or visit nyc.gov/contactscrie.

You can visit our SCRIE office at 66 John Street, 3rd floor, New York, NY.

We are open Monday through Friday, between 8:30 AM and 4:30 PM.

Scrie - Senior Citizen Rent Increase Exemption Initial Application Form - 2015 Page 2

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