Drie - Disability Rent Increase Exemption Initial Application Form - 2015 Page 2

Initial Application for Disability Rent Increase Exemption

Page 2

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

VA

PENSION

WAGES AND

INTEREST AND

ALL OTHER INCOME

,

,

,

/

MEMBER

BOARDER

BENEFITS

ANNUITY

IRA UNEMPLOYMENT

DIVIDENDS

For ex.: Boarder, Public Assistance

SSA

SSI

SSD

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.

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 DRIE 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 author-

ize 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 information 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 identifying 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 informa-

tion 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?

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Did you sign and date the application?

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Did you include a copy of your Social Security or VA disability award letter specifying the benefit award date?

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Did you include proof of your age?

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

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lord? 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

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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 landlord and a copy

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of the DHCR Rent History or DHCR apartment registration?

For Mitchell-Lama, Section 213 coop and HDFC coop apartments: Did you include a rent printout or letter from your man-

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agement office specifying the start date, and the amount of your most recent rent increase?

For Building Improvements (Major Capital Improvement): Did you include a copy of the building improvement (MCI) increase? Please

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note: Rent increases for new appliances (stove, refrigerator, etc.) are not covered by DRIE.

Did you include proof of income for all household members including yourself and co-tenants for the calendar year prior to

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

Income tax returns (if filed)

Public assistance budget statement

Social security benefit statement (SSA/SSI/SSD)

Student status letter for any non-working students living

IRA/Annuity statement, including earnings statement

in your household

Pension statement

Signed letter from friend/family stating amount of mone-

Signed letter from boarder stating rental payments

tary assistance

1099/W2 statement

GENERAL INFORMATION AND ASSISTANCE

If you need help or have questions please contact 311 or email DRIE@finance.nyc.gov.

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

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