Senior Citizen Rent Increase Exemption (Scrie) Application For Benefit Takeover - 2011 Page 2
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3NYC DEPARTMENT OF FINANCE
PROGRAM OPERATIONS DIVISION
SENIOR CITIZEN RENT INCREASE EXEMPTION (SCRIE)
G
APPLICATION FOR BENEFIT TAKEOVER
TM
Finance
Mail to: NYC Department of Finance, SCRIE Program, 59 Maiden Lane, 22nd Floor, New York, NY 10038
Instructions: Please mail the completed and signed application, with copies of all requested documents.
SECTION I - DECEASED TENANT INFORMATION
1. SCRIE
Docket #:__________________ 2. Name: ________________________________________________
FIRST
LAST
3. Address:
____________________________________________________________ Apt. #:
_____________
NUMBER
STREET NAME
Borough:
Zip Code:
_____________________________________________________________________________________
____________________________________
4. Date of Death: __________________ 5. Death Certificate Number:
___________________________________________________
Attach a copy of the Death Certificate to your application.
MONTH / DAY / YEAR
SECTION II - NEW TENANT OF RECORD INFORMATION
1. Name:
______________________________________________________________________________________________________________________________________________
FIRST NAME
LAST NAME
2. Address:
____________________________________________________________ Apt. #:
_____________
NUMBER
STREET NAME
Borough:
Zip Code:
_____________________________________________________________________________________
____________________________________
3. Telephone: (_____) ____________________ 4. Email Address: _______________________________
5. Date of Birth: ___________________ 6. Relationship to Deceased:
__________________________________________________
MONTH / DAY / YEAR
SECTION III - HOUSEHOLD INFORMATION - List all individuals living in household
NAME
RELATIONSHIP
DATE OF BIRTH
SOCIAL SECURITY NUMBER
Self
1.
2.
3.
SECTION IV - INCOME FOR CALENDAR YEAR PRIOR TO APPLICATION - Enter annual amounts
NAME
SOCIAL SECURITY
SSI
PENSION
WAGES
INTEREST
PUBLIC
OTHER
&
INCOME
DIVIDENDS
ASSISTANCE
Self
$
1.
2.
3.
Visit Finance at nyc.gov/finance
SCRIE Benefit Takeover Appl. Rev. 09.08.11
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