APPLICATION FOR CERTIFICATION OF NO HARASSMENT OR EXEMPTION 1. Check (a) or (b) I am applying for: 2. (a)Certification of No Harassment (b)Exemption If you are applying for an exemption, please indicate the letter designation for the exemption you are seeking. (See instructions.) _______________ INQUIRY PERIOD WILL BE ESTABLISHED BY HPD 3. INQUIRY PERIOD / month 4. / day to year / month / day year Premises for which certification or exemption sought. (subject premises) _____________________________________________________________________________ house number street borough Zip Code block _________ lot _________ Building name by which the subject premises is known:_________________________________ ______________________________________________________________________________ 5. Name and mailing address of Applicant. ( Must be an individual, please see instructions). ________________________________________________ name _______________________________________________________________________________ house number street city/state Zip Code Telephone: Business: ( Home: ( ) ) Email Address:______________________________ 6. Relationship of applicant to subject premises (for example: owner, contract vendee in possession, officer of owner) ___________________________________________________________________ 7. Name(s) of deed owner(s) __________________________________________________ Remember to submit an original certified copy of all recorded deed(s) to cover the inquiry period. You can obtain a certified copy from the City Register in the borough where the premises are located. American LegalNet, Inc. www.FormsWorkflow.com 8. Please describe the subject premises. In 8(a) describe the actual appearance of the premises. In 8(b) describe the legal configuration of the units in the premises, if different. a. Actual appearance of premises: SRO Units Residential Units b. vacant occupied Commercial Units Non SRO Units vacant occupied If different, describe the legal configuration of the units in the premises. Remember to include a certified copy of the Certificate of Occupancy for the building, if one exists. If there is no Certificate of Occupancy, please obtain a letter from the Department of Buildings that the building does not have a Certification of Occupancy. SRO Units Residential Units Commercial Units Non SRO Units vacant occupied vacant occupied 9. For what purpose are you applying for a certification of no harassment or exemption? Briefly describe the work you intend to do at the premises. Copies of plans may be requested. 10. Have you ever applied for a certification of no harassment before? If so, indicate the building(s) for which the certification of no harassment was sought and the disposition of the application(s). American LegalNet, Inc. www.FormsWorkflow.com 11. Please provide the requested information for the applicant and any other individuals who exercises any discretion in the management of the premises or was involved in the operation of the building during the inquiry period, e.g. managing agents, on site managers, superintendents, caretakers, rent collectors, former owners, etc. Name, Address and Relationship to the premises Birthdate and Social Security # Person or Entity By Whom Employed Dates During Which Services Were Performed American LegalNet, Inc. www.FormsWorkflow.com 12. Complete this item if the owner of the premises is a corporation, LLC or a partnership. If the owner is one of the entities, in addition to the information provided in the columns below please submit an Opinion of Counsel letter which authorizes the individual to file the application. An opinion of counsel letter is a letter by an attorney that the person signing on behalf of the applicant, corporation, partnership or limited liability corporation, is entitled to file and act on behalf of the entity and to make all of the representations and commitments therein. Name Relationship to owner Residence and Business Address Business and Home Phone American LegalNet, Inc. www.FormsWorkflow.com 13. List the names of all owners who held their interest during the Inquiry Period. For each owner, provide address and phone number, if known, and indicate the period of ownership. 14. Has the premises been managed or operated by an entity other than the owner during the Inquiry Period? (For example, net lessee, mortgagee in possession, receiver, etc.) If so, provide name, address, phone number and description of relationship to the premises for each such entity. Be certain to indicate the time period during which the premises were operated by the entity in question. American LegalNet, Inc. www.FormsWorkflow.com 15. List all criminal convictions of person or entities listed above in items 11, 12, 13, and 14 which occurred during the inquiry period, as well as all currently pending criminal proceedings in which such persons are defendants. Note that requests for additional information and documentation may be made in the future. Name Court where proceeding pending or conviction Case or Docket No. Name of Complainant(s) Disposition or Current Status American LegalNet, Inc. www.FormsWorkflow.com 16. List all proceedings before the Division of Housing and Community Renewal (DHCR) involving the subject premises which were commenced, pending or resolved after the opening date of the inquiry period to and including the date of filing this application. Note that requests for additional information and documentation may be made in the future. Name Case or Docket No. Nature of Proceedings Attorneys for parties, if any Disposition or Current Status American LegalNet, Inc. www.FormsWorkflow.com 17. List all current residential and commercial occupants of the subject premises and provide requested information as to each. If there are any changes in the information provided here during the pendency of this application please inform us immediately in writing. Name Date occupant began living at the premises Room, Apartment or Commercial Unit Telephone No. of Occupant Amount of Monthly Rent American LegalNet, Inc. www.FormsWorkflow.com 18. List all former occupants who have surrendered the units they occupied at the subject premises, or otherwise vacated, from the opening date of the inquiry period to the present. If you have not owned the premises during the entire inquiry period, please contact former owners for this information. Name Unit Occupied Date Vacated Reason for Vacating (e.g. Court Action) Current Address and Phone No. of Former Occupant American LegalNet, Inc. www.FormsWorkflow.com 19. List all lawsuits relating to the subject premises commenced, pending or resolved during the inquiry period. Note that requests for additional information and documentation may be made in the future. Title of Action Index No. and Court Attorney(s) for Plaintiff(s) (Name, Address, and Phone No.) Attorney(s) for Defendants(s) (Name, Address, and Phone No.) Nature of Action Disposition or Current Status American LegalNet, Inc. www.FormsWorkflow.com Please answer questions 20, 21, and 22 below in good faith, to the best of your ability. If you do not have sufficient personal knowledge to answer these questions, or any other questions on this application, please endeavor to obtain the required information by contacting former owners, tenants, government agencies, etc. 20. a) b) 21. a) b) 22. a) b) Has any owner of the premises, its agents, employees or other persons acting on its behalf used force, or threatened the use of force against the person or property of any occupant of the premises during the inquiry period? Yes No If the answer to “a” is yes, give details Have there been any interruptions or discontinuations of services at the premises during the Inquiry Period, including, but not limited to: heat, hot water, cold water, electricity, gas and/or elevator service? Yes No If the answer to “a” is yes, give details Has any owner of the premises, its agents, employees or other person acting on its behalf removed the possessions of any occupant from the dwelling unit; removed, plugged or otherwise rendered the lock on an entrance door inoperable or changed the lock on an entrance door without supplying the occupant with a key? Yes No If the answer to “a” is yes, give details American LegalNet, Inc. www.FormsWorkflow.com I have read the within application and believe its entire contents to be true and complete. The owner of the property hereby consents to access by the Department of Housing Preservation and Development to the premises which are the subject of this Application, at all times and without prior notice, for the purpose of investigating all facts relevant to this Application, from the date hereof until the date upon which the Department of Housing Preservation and Development makes a final determination with respect to the grant or denial of the Certification of No Harassment pursuant to this Application. It is understood that failure to provide such access when requested will prevent the processing of this application and may, in the discretion of the Department, cause denial of the issuance of a Certification. Further, it is understood that if this application contains any false or misleading statements, or material omissions the application may be denied. Further, it is understood that the applicant and/or undersigned must obtain a Certification of No Harassment from the Department of Housing Preservation and Development and all necessary permits from the Department of Buildings prior to commencing the work at the subject premises which is the subject of this Application. _______________________________________ Applicant's Signature _________________________________________ Applicant's Signature _______________________________________ Print Name Above _________________________________________ Print Name Above _______________________________________ Relationship to Property __________________________________________ Relationship to the Property ________________________________________ __________________________________________ Individual Fee Owner's Signature Individual Fee Owner's Signature ________________________________________ ___________________________________________ Print Name Above Print Name Above __________________________________________ Corporate Fee Owner's Signature __________________________________________ Print Name and Title Above Sworn to this _______ day of _________________, 200__. ____________________________________________ NOTARY American LegalNet, Inc. www.FormsWorkflow.com