Disability Rent Increase Exemption Renewal/recertification - 2011
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1
2DRIE
DISABILITY RENT INCREASE EXEMPTION
NYC DEPARTMENT OF FINANCE
PROGRAM OPERATIONS DIVISION
G
RENEWAL/RECERTIFICATION
TM
Finance
Mail to: NYC Department of Finance, Attn: DRIE, 59 Maiden Lane, 22nd Floor, New York, NY 10038
Instructions: Use this form if you are presently receiving a DRIE benefit and are recertifying your eligibility status and
renewing your application for the DRIE benefit. Finance is required to recertify your eligibility for DRIE benefits at the end
of your benefit period indicated on your DRIE Order of Approval. Please forward the completed, signed application and a
fully signed copy of your most recent renewal lease or rent order to the address above. See attached for further details
regarding required proof of residency documents.
SECTION A - APPLICANT INFORMATION
1. Name of Applicant
with a Disability: a. ____________________________________ b. _________________________________________
FIRST NAME
LAST NAME
2. Address: ______________ 3. _______________________________________________ 4. Apt. #: ______________
NUMBER
STREET NAME
5. Borough: __________________________________________________
6. Zip Code: ___________________________
7. Daytime Phone Number: (____) ____________________ 8. Email Address: ___________________________________
9. DRIE Application #: ________________________________
10. Current Rent: $ ________________ Start Date: _______________________ End Date: ________________________
11. New Rent: $ ___________________ Start Date: ______________________ End Date: ________________________
SECTION B - ELIGIBILITY INFORMATION
12. How many people reside in the household? ______________________
13. How many people in the household receive income of any kind (work, benefits, etc.)? ____________________________
14. Please indicate the total/aggregate household income for the previous year: $ __________________________________
(Include income for all household members)
15. Are you receiving any of the following benefits? (Check all that apply)
Social Security Income (SSI)
Social Security Disability Insurance (SSDI)
K
K
Veteran Disability Pension/Compensation
Disability-related Medicaid and have received
(Must be Military
K
K
either SSI or SSDI in the past
service-related disability pension or compensation)
16. Do you or any other member of your household receive a Senior Citizen Rent Increase Exemption (SCRIE)?
Yes
No
K
K
17. Do you receive Section-8 or any other federal housing subsidy?
Yes
No
K
K
SECTION C - CERTIFICATION
I certify that all information contained in this application is true and correct to the best of my knowledge and belief. I also certify that I contin-
ue to meet the DRIE eligibility criteria. I understand that willful making of any false statement of material fact herein will subject me to the pro-
visions of law relevant to the making and filing of false instruments and will render this application null and void.
____________________________________________________________ ______________________________________
Signature of Applicant with a Disability
Date
____________________________________________________________ ______________________________________
Signature of Preparer (If other than applicant)
Date
Would you like a copy of the DRIE Renewal/Recertification sent to the preparer?
Yes
No
K
K
(If “YES,” provide the preparerʼs name and mailing address, daytime phone, and/or fax number below.)
Name of Preparer: ________________________________________ ___________________________________________
FIRST NAME
LAST NAME
Preparerʼs Address: ______________ _________________________________________________
_________________
. #
NUMBER
STREET NAME
APT
________________________________
________________ (______) ________________ (______) _______________
BOROUGH
ZIP CODE
PHONE NUMBER
FAX NUMBER
DRIE Renewal/Recert. 01/24/11
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