Drie - Disability Rent Increase Exemption Initial Application Form

DRIE

NYC DEPARTMENT OF FINANCE

PROGRAM OPERATIONS DIVISION

FOR OFFICE USE ONLY

DISABILITY 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 - DRIE Unit, 59 Maiden Lane, 22nd Floor, New York, NY 10038

SECTION 1 - ELIGIBILITY REQUIREMENTS

To qualify for the Disability Rent Increase Exemption, you must:

Be at least 18 years old

Be named on the lease or rent order or have been granted succession rights to the apartment

Rent an apartment defined as eligible under the law (Rent Stabilized, Rent Controlled, Mitchell-Lama, Limited

Dividend, Redevelopment, Housing Development Fund Company (HDFC) cooperative, Section 213 cooperative)

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

Receive Supplemental Security Income (SSI), Social Security Disability Income (SSDI), VA Disability Pension, VA

Compensation, or Disability-related Medicaid.

*Allowable deductions are Federal, State, Local and Social Security taxes paid.

Tenants who live in private homes, a New York City Housing Authority development and/or receive Section 8 rental sub-

sidies do not qualify for DRIE benefits.

SECTION 2 - APPLICANT INFORMATION

1. Name of

Tenant: a. __________________________________________

b. _____________________________________________

FIRST NAME

LAST NAME

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

NUMBER

STREET NAME

5. City: _____________________________ 6. Zip 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

HDFC coop

Section 213 coop

Mitchell-Lama

(Also Limited Dividend and Redevelopment)

12. Check all that applies to your rent increase:

1-yr renewal lease

2-yr renewal lease

Fuel

Building Improvement (MCI)

Carrying charge increase

Temporary surcharge or assessment

Maximum Collectible Rent (MCR)

Other: _________________________

13. Specify which federal disability benefit(s)

you receive. Check all that apply:

SSI

SSDI

VA Disability Pension/VA Compensation

Disability-related Medicaid

14. Have you ever applied for DRIE before?

Yes

If “Yes”, enter the ID Number: __________________________

SECTION 3 - TENANT REPRESENTATIVE

You can have copies of your DRIE 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. #: ___________

NUMBER

STREET NAME

6. City: _____________________________ 7. Zip Code: ____________

8. Telephone (_____)__________________________

DRIE Initial Application - Rev. 03.31.2015

Drie - Disability Rent Increase Exemption Initial Application Form - 2015

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