FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner

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1 FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner Office of Procedures POLICY BULLETIN #07-62-OPE (This Policy Bulletin Replaces PB # OPE) REVISIONS TO FORMS W-146E, W-147E, W-147M AND W-147Q May 24, 2007 This procedure can now be accessed on the FIAweb. Subtopic(s): Forms This policy bulletin is to inform all Job Center staff that the following rent-related forms have been revised to conform to the Agency s formatting requirements, and have received minor updates to reflect current agency terminology: Request to Pay Rent Arrears in Excess of Public Assistance Maximum Shelter Allowance (W-146E) NYCHA Security Agreement (W-147E) Landlord s Statement (W-147M) Primary Tenant s Statement Regarding Occupancy of Secondary Tenant (W-147Q) Changes are as follows: W-146E The LLF designation has been added to the header indicating the form meets Local Law 73 requirements. The form has been separated into English and Spanish versions W-147E The logo has been updated In the section below the logo, a Date line has been added and the term I.S. Center has been replaced with Center. The Social Services principal offices address has been changed to 250 Broadway, New York, NY The term client has been replaced by applicant/participant. At the bottom of the form, the term Eligibility Specialist has been replaced by Worker s Signature. HAVE QUESTIONS ABOUT THIS PROCEDURE? Call then press 2 at the prompt followed by 765 or send an to FIA Call Center Distribution: X

2 PB #07-62-OPE The instructions at the bottom of the form have been changed from Prepare in duplicate. Give original to client to take to NYCHA Management Office; file copy in case record to Scan a copy of this document into the electronic file and give the original to the applicant/participant to take to NYCHA Management Office. W-147M The logo has been updated The term I.S. Center has been replaced with Center. W-147Q The LLF designation has been added to the header indicating the form meets Local Law 73 requirements. The form has been separated into English and Spanish versions. Center Directors must ensure that all previous versions of these forms are removed from circulation and recycled. Effective Immediately Please use Print on Demand to obtain copies of forms. Attachments: W-146E Request to Pay Rent Arrears in Excess of Public Assistance Maximum Shelter Allowance (Rev. 5/24/07) W-146E (S) Request to Pay Rent Arrears in Excess of Public Assistance Maximum Shelter Allowance (5/24/07) (Spanish) W-147E NYCHA Security Agreement (Rev. 5/24/07) W-147M Landlord s Statement (Rev. 5/24/07) W-147Q Primary Tenant s Statement Regarding Occupancy of Secondary Tenant (Rev. 5/24/07) W-147Q (S) Primary Tenant s Statement Regarding Occupancy of Secondary Tenant (5/24/07) (Spanish) FIA Policy, Procedures and Training 2 Office of Procedures

3 Form W-146E LLF Rev. 5/24/07 Case Number: Case Name: Request to Pay Rent Arrears in Excess of Public Assistance Maximum Shelter Allowance I,, am requesting assistance to pay rent arrears to avoid eviction. (Name) I understand that my rent is in excess of the public assistance maximum shelter allowance for my household size. I understand that in order to have this request approved, I must provide documentation showing how future rent payments will be made, including a statement from a third party that will help me pay my rent. I understand that the rent arrears payment will be made in the form of a check made payable to my landlord. If any of the rent arrears advanced to me duplicates assistance previously given to me by the Human Resources Administration, I agree to the recoupment of such portion of the arrears payment. Applicant/Participant's Signature: Agreement by Third Party to Pay Excess Rent I,, Social Security number, affirm that: (Name) I agree to pay the excess rent in the amount of $ for the apartment occupied by at, (Applicant/Participant's Name) (Applicant/Participant's Address) effective. The payment will be made directly to the: aforementioned applicant/participant landlord (name and address): My income, indicated below, is sufficient to meet all of my expenses as well as the excess rent payment. Monthly household income: Shelter expense: The proof of income I am submitting is: Pay stubs, W-2 form and /or letter from employer on employer's stationery from: Proof of other income/source: (Employer's Name and Address) My relationship to the applicant/participant is: My address is: The above information is true and correct. Signature:

4 Form W-146E (S) LLF 5/24/07 Fecha: Número del Caso: Nombre del Caso: Solicitud para Pagar Alquiler Atrasado que Exceda la Asignación Máxima de Asistencia Pública para Refugio Yo,, solicito asistencia para pagar el alquiler atrasado para evitar (Nombre) ser desalojado(a). Estoy consciente de que mi alquiler sobrepasa la asignación máxima de asistencia pública para refugio dado el tamaño de mi familia. Además, comprendo que para que se apruebe la presente solicitud, he de proporcionar documentación que muestre como serán efectuados los pagos posteriores de alquiler, incluida una declaración de una tercera parte que me ayudará a pagar el alquiler. Más aún, comprendo que el pago atrasado de alquiler será efectuado mediante cheque pagadero a mi casero(a). En caso de que alguno de los atrasos de alquiler que se me hayan adelantado reproduzca asistencia anteriormente percibida por mí de parte de la Administración de Recursos Humanos, consiento en reembolsar la cantidad del pago de atrasos que corresponda. Firma del Solicitante/Participante: Fecha: Acuerdo por Tercera Parte para Pagar el Alquiler en Exceso Yo,, número de Seguro Social,, doy fe de que: (Nombre) acuerdo pagar el alquiler en exceso por la cantidad de $ para el apartamento ocupado por en, a partir de (Nombre del Solicitante/Participante) (Fecha) antemencionado solicitante/participante casero (nombre, apellido y dirección): (Dirección del Solicitante/Participante). El pago se efectuará directamente a nombre del: La cantidad de mis ingresos, indicada más abajo, es suficiente para cubrir todos mis gastos, asimismo como los pagos de alquiler en exceso. Ingresos mensuales del hogar: Gastos de albergue: El comprobante de ingreso que presentaré es el siguiente: Talones de paga, formulario W-2 y/o carta por parte del empleador o en papel con el membrete de tal: (Nombre y Dirección del Empleador) Comprobante de otros ingresos/fuentes de tales: Mi relación con el solicitante/participante es la siguiente: Mi dirección es: Los datos más arriba son verídicos y exactos. Firma: Fecha:

5 Form W-147E Rev. 5/24/07 Case Number: Case Name: Center: Caseload: NYCHA SECURITY AGREEMENT This AGREEMENT is between the New York City Department of Social Services (NYCDSS), a social services county of the State of New York having its principal offices at 250 Broadway, New York, NY 10007, and the New York City Housing Authority (NYCHA), regarding the applicant/participant and apartment listed below. Applicant/Participant Name: Applicant/Participant Address: City: State: Zip: This agreement is made with the understanding that it is limited to unpaid rent or damages: Incurred while the participant is a recipient of public assistance and the claim is made while the participant is receiving public assistance (recurring public assistance cases only). Incurred while the applicant is a recipient of public assistance and six months thereafter (one-shot assistance cases only). In accordance with Section 143-c of the Social Services Law and Section of the New York State Social Services Regulations, this agreement to pay such unpaid rent or damages not to exceed $ (monthly rental amount) is issued in lieu of a security deposit for the above-named public assistance participant. Worker's Signature Date Instructions: Scan a copy of this document into the electronic folder and give the original to the applicant/participant to take to NYCHA Management Office.

6 Form W-147M Rev. 5/24/07 Landlord's Statement Center/DHS Site: Case Name: Case Number: Caseload/DHS Worker Telephone Number: I am (or we are) the landlord (Managing Agent) of the premises located at Address Landlord/Managing Agent's Name Apartment Number Borough Zip Code I am (or we are) not the broker nor in any way associated with the management of the agency charging a broker's fee for the procurement of the above premises. I (or we) agree that I (or we) will not receive any part or all of the broker's fee directly or indirectly from the broker. I (or we) hereby attest that I (or we) will not rent the premises without the services of the broker listed below: Name of Broker License Number Address Telephone Number Failure to provide true and accurate statements is punishable as a Class A Misdemeanor pursuant to Penal Law (offering a false instrument for filing to a public office or a public servant). Signature of Landlord Landlord's Phone Number Landlord's Address

7 Form W-147Q LLF Rev. 5/24/07 Primary Tenant's Statement Regarding Occupancy of Secondary Tenant Primary Tenant's Name: Secondary Tenant's Name: Case Number (if any): Address: Address: Apt. Number: Apt. Number: Borough: Zip Code: Borough: Zip Code: I,, do hereby declare that I am the primary tenant of apartment located at. I do also declare that also lives on these premises. (name of secondary tenant) I charge $ per month rent for providing shelter (heat/utilities). Attached is a copy of my lease or other documentation demonstrating that I am a legal tenant of this apartment. Rent payment method (check the applicable boxes): Rent is paid directly to the landlord. Rent is paid directly to me. I share meals with the secondary tenant named above: Yes No I swear under penalty of perjury that the information I have given on this form is correct and complete to the best of my knowledge. Signature of Primary Tenant Telephone Date

8 Form W-147Q (S) LLF 5/24/07 Declaración del Inquilino Principal con Respecto a la Ocupación del Inquilino Secundario Nombre del Inquilino Principal: Nombre del Inquilino Secundario: Núm. del Caso (de haberlo): Dirección: Dirección: Núm. de Apto.: Núm. de Apto.: Condado: Código Postal: Condado: Código Postal: Yo, principal del apartamento Además declaro que localizado en (nombre del inquilino secundario), por la presente declaro que soy el inquilino también vive en este local.. Yo cobro $ mensualmente por alquiler para proveer vivienda (calefacción/electricidad y/o gas). Adjunta se encuentra una copia de mi contrato de alquiler y otros documentos que comprueban que yo soy el inquilino legal de este apartamento. Método de pago del alquiler (marque las casillas que correspondan): El alquiler se paga directamente al casero. El alquiler se me paga directamente a mí. Comparto comidas con el inquilino secundario nombrado más arriba: Sí No Juro, so pena de perjurio, que la información que he proporcionado en este formulario es correcta y completa según mi leal saber y entender. Firma del Inquilino Principal Teléfono Fecha

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