Application For Appeal Of The Disability Rent Increase Exemption Determination Form Page 3
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5Application for Appeal of the DRIE Determination
Page 3
SECTION D - CERTIFICATION
TENANT
I certify that all information contained in this application is true and correct to the best of my knowl-
edge and belief. I understand that willful making of any false statement of material fact herein will
subject me to the provisions of law relevant to the making and filing of false instruments and will ren-
der this application null and void.
Be advised that if you claim that you qualify for benefits based on meeting the required in-
come threshold, and at any point in the future a current household member whose income you
did not include in your application attempts to claim rights to your apartment, you will be re-
sponsible to repay the City the full amount of any Disabled Rent Increase Exemption bene-
fits that you received improperly plus any interest charges.
_________________________________________
____________________________________
Signature
Date
_________________________________________
____________________________________
Signature of Preparer (If applicable)
Date
OWNER/LANDLORD
I certify that all information contained in this application is true and correct to the best of my knowl-
edge and belief. I understand that willful making of any false statement of material fact herein will
subject me to the provisions of law relevant to the making and filing of false instruments and will ren-
der this application null and void.
I further certify that I have notified the tenant of this appeal, in writing, with an explanation
of the grounds of my appeal.
_________________________________________
____________________________________
Signature
Date
_________________________________________
____________________________________
Signature of Preparer (If applicable)
Date
PRIVACY ACT NOTIFICATION
The Federal Privacy Act of 1974, as amended, requires agencies requesting Social Security Num-
bers 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 tenants is mandatory and is re-
quired by section 11-102.1 of the Administrative Code of the City of New York. Such numbers dis-
closed on any report or return 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 tax-
payers who are or may be subject to taxes administered and collected by the Department of Fi-
nance. Such numbers may also be disclosed as part of information contained in the taxpayerʼs
return to another department, person, agency or entity as may be required by law, or if the appli-
cant or tenant gives written authorization to the Department of Finance.
Please keep a copy of this application for your records.
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