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Application For Certification Of No Harassment Form. This is a New York form and can be use in New York Local County.
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Tags: Application For Certification Of No Harassment, New York Local County, New York
nyc.gov/hpd
MATHEW M. WAMBUA
Commissioner
DOUGLAS APPLE
First Deputy Commissioner
VITO MUSTACIUOLO
Deputy Commissioner
DEBORAH RAND
Assistant Commissioner
Office of Enforcement and Neighborhood Services
Housing Litigation Division
100 Gold Street
New York, N.Y. 10038
APPLICATION FOR A CERTIFICATION OF NO HARASSMENT
PURSUANT TO §96-110, §93-90, §98-70, AND/OR §23-013
OF THE NEW YORK CITY ZONING RESOLUTION
FILING INSTRUCTIONS
Property: Use this application form if the property for which you seek a certification of no harassment is
located in:
• The Special Clinton District.
• The Special Hudson Yards District.
• Preservation Area P-2 of the Special Garment Center District.
• The Greenpoint-Williamsburg anti-harassment area.
• The Special West Chelsea District.
Who May Apply: The applicant must be an individual natural person and must be either (i) a title holder,
a contract vendee, or a net lessee under a lease with at least 10 years remaining in its term ("owner"), or
(ii) a principal or officer of an owner who is authorized to sign on behalf of and bind such owner. If the
applicant does not have legal authority to authorize the Department of Housing Preservation and
Development ("HPD") to enter all common areas of the property (for example, if the applicant is a contract
vendee or is an owner who has leased the property to someone else), then the application must also be
signed by an individual natural person who has such authority. If the applicant is a contract vendee, then
the application must also be signed by an individual natural person who is authorized to sign on behalf of
the title holder.
Number of copies: Submit one original and one copy of this application and all supporting documents.
Fee: Enclose a certified or bank check or a money order payable to "NYC Commissioner of Finance" for
the following amount:
• $500 if the property contains 1-10 dwelling units
• $1,500 if the property contains 11-30 dwelling units
• $2,500 if the property contains 31- 50 dwelling units
• $3,500 if the property contains more than 50 dwelling units
Submission Method: Submit the application and fee by mail (regular, certified, or registered), private
courier, or hand delivery. Hand deliveries are only accepted Monday through Friday from 9 a.m. to
11 a.m.
Submission Location: Submit the application and fee to Anti-Harassment Unit, Department of Housing
Preservation and Development, 100 Gold Street, Room 3-Q3, New York, NY 10038, Attention: Rhonda
Waldon.
Inquiries: Direct all inquiries regarding this application to: (212)863-8266.
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Additional Pages: If the answer to any question in this application requires additional space, please add
pages to the application as necessary and indicate the number of the question to which the additional
information pertains.
Obligation to Update: If any information stated in the application changes before HPD makes a final
determination regarding whether harassment occurred, the applicant must promptly update the application
with such new information and submit it to HPD. If the new information includes a change of ownership or
any other facts that make the original applicant ineligible to submit the application, HPD may require that
the amended application be executed by an eligible individual.
Withdrawal: An application may not be withdrawn after HPD issues either (i) an initial determination that
there is reasonable cause to believe that harassment occurred, or (ii) a final determination that
harassment occurred.
As used in this application, "referral date" means:
• September 5, 1973 if the property is located in the Special Clinton District;
• June 21, 2004 if the property is located in the Special Hudson Yards District;
• June 21, 2004 if the property is located in Preservation Area P-2 of the Special Garment Center
District;
• October 4, 2004 if the property is located in the Greenpoint-Williamsburg anti-harassment area
defined in Zoning Resolution §23-013; or
• December 20, 2004 if the property is located in the Special West Chelsea District.
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nyc.gov/hpd
1.
MATHEW M. WAMBUA
Commissioner
DOUGLAS APPLE
First Deputy Commissioner
VITO MUSTACIUOLO
Deputy Commissioner
DEBORAH RAND
Assistant Commissioner
Office of Enforcement and Neighborhood Services
Housing Litigation Division
100 Gold Street
New York, N.Y. 10038
Property: Identify the property that is the subject of this application ("property").
Borough:
Manhattan
________________
Brooklyn
Block: ________
Lot(s):
Street Address:
____________________________________________________________________
Check the box that applies:
The property is located in the Special Clinton District.
The property is located in the Special Hudson Yards District.
The property is located in Preservation Area P-2 of the Special Garment Center District.
The property is located in the Greenpoint-Williamsburg anti-harassment area defined in
Zoning Resolution §23-013.
The property is located in the Special West Chelsea District.
If none of the above applies, please call (212)863-8266 because you are using the wrong form.
2.
Building Configuration: Attach either an original certified copy of the certificate of occupancy or
original certified letter from the Department of Buildings stating that the building does not have a
certificate of occupancy. Describe the legal and actual configuration of the building below.
Type of Unit
Legal Configuration Number of Units
Actual Configuration Number of Units
Apartment Dwelling Units
SRO Dwelling Units
Total Dwelling Units
Commercial Units
What is the basis of the legal configuration described above?
Certificate of Occupancy
“I” Card
Other City Data (Specify):
_____________________________________________________
Are the legal and actual configurations identical?
Yes.
No (Describe the discrepancy):
_________________________________________________.
3.
Building Occupancy: Is the building currently vacant?
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Yes (How long has the building been vacant?
______________________________________).
No (Describe the current occupancy below).
Type of Unit
Occupied
Vacant
Total
Apartment Dwelling Units
SRO Dwelling Units
Total Dwelling Units
Commercial Units
4.
Applicant: Identify the applicant (the applicant must be a human being, not an entity).
Name:
________________________________________________________________________
____
Social Security Number: ______/____/________
Date of Birth: ____/____/________
Mailing Address:
____________________________________________________________________
Business Telephone Number: ______________
__________________
Mobile Telephone Number:
Email Address: _________________________
_____________________________
Fax Number:
Relationship to the property (attach documentation):
________________________________________
5.
Access Authorizer: Does the applicant identified in response to Question 4 have legal authority
to authorize the Department of Housing Preservation and Development ("HPD") to enter all
common areas of the property?
Yes.
No (identify the person who will sign this application to authorize such access)
Name:
________________________________________________________________________
____
Social Security Number: ______/____/________
Date of Birth: ____/____/________
Mailing Address:
____________________________________________________________________
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Business Telephone Number: ______________
__________________
Mobile Telephone Number:
Email Address: _________________________
_____________________________
Fax Number:
Relationship to the property (attach documentation):
________________________________________
6.
7.
Current Owners: List each current holder of title to the property:
Name
Date of Birth
SSN or EIN
Prior Owners: List each prior holder of title to the property since the referral date and attach an
original certified copy of every deed, mortgage, and net lease since the referral date.
Name
Date of Birth (If Known)
SSN or EIN (If Known)
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8.
Current Principals and Officers: If title to the property is held by an entity rather than by a
person, list (i) every director, general partner, managing partner, or managing member of such
entity, (ii) every officer of such entity, (iii) every other person authorized to sign for and bind such
entity, and (iv) every person or entity holding a 10% or more economic interest in such entity.
Name
Date of SSN or
Birth
EIN
Relationship
to Owner
Address
Telephone
Number
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9.
Principals and Officers Of Prior Owners: If title to the property was previously held by an entity
rather than a person at any time since the referral date, list (i) every director, general partner,
managing partner, or managing member of such entity, (ii) every officer of such entity, (iii) every
other person authorized to sign for and bind such entity, and (iv) every person or entity holding a
10% or more economic interest in such entity.
Name
Date of Birth
(If Known)
SSN or EIN
(If Known)
Relationship
to Owner
Address
Telephone
Number
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10.
Management: List each person who served as a managing agent, served as a superintendent,
collected rents, supervised or ordered repairs, or exercised any other discretion in the
management of the property from the referral date to the present.
Period of
Nature of
Name
Employer
Address
Role
Service
Service
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11.
Prior Applications By The Applicant: Has the owner, the applicant, or any other representative
acting on behalf of the owner ever previously applied for a certification of no harassment for any
property?
No.
Yes (Indicate each property for which the applicant sought a certification of no harassment
and the disposition of each such application).
12.
Prior Applications For The Property: Has anyone ever submitted an application for a
certification of no harassment (or an exemption or waiver from the requirement for a certification of
no harassment) to HPD with respect to the property?
No.
Yes (Indicate the date of the application, whether HPD granted or denied the certification of
no harassment, and any other relevant details)
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13.
Name
Occupants: List all current residential and commercial occupants of the property.
Unit
Initial Occupancy Date
Telephone
Number
Monthly Rent
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14. Former Occupants: List each former occupant who vacated a dwelling unit or rooming unit at the
property after the referral date, whether through eviction, relocation, surrender of occupancy rights,
or any other means. If such occupant was relocated, please provide details or a copy of the
agreement if one exists.
Name Of Occupant
Unit
Date
Vacated
Reason For
Vacating
Current Address And
Phone Number
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15.
Work: Briefly describe the reason for this application (i.e., the alteration or demolition work to be
performed at the property).
Have any applications for permits been filed with the Department of Buildings for work at the
property which would require a certification of no harassment?
No (Even if no such applications for permits have been filed with the Department of
Buildings, HPD may request copies of architectural plans).
Yes (Attach a copy of each such application, stamped by the Department of Buildings, and
all attachments thereto).
Is any construction work currently in progress?
No.
Yes (Provide details below).
16.
Relocation: Will any occupants be relocated or displaced as a result of the alteration or demolition
work to be performed at the property?
No.
Yes (Provide details below).
Monthly Reason For Relocation or
Name
Unit
Rent
Displacement
Phone Number
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17.
Criminal Convictions And Proceedings: Have any of the persons or entities listed above in
items 4-8 ever been convicted of a crime, or is any such person or entity currently a defendant in a
pending criminal proceeding?
No.
Yes (Provide details below).
Name
Court
Docket Number
Case Name
Disposition
18.
DHCR Proceedings: Since the referral date, have there been any harassment proceedings,
decrease in service proceedings, or other proceedings with regard to the property before the
Division of Housing and Community Renewal?
No.
Yes (Provide details below and attach a copy of each complaint and final disposition, if
any).
Docket
Nature of
Attorneys for
Disposition or
Party Names Dates
Number
Proceeding
Parties
Current Status
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19.
Other Administrative Proceedings: Since the referral date, have there been any administrative
proceedings with regard to the property before any governmental or quasi-governmental authority
other than the Division of Housing and Community Renewal?
No.
Yes (Provide details below and attach a copy of each complaint and final disposition, if
any).
Docket
Nature of
Attorneys for
Disposition or
Party Names Dates
Number
Proceeding
Parties
Current Status
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20.
Litigation: Since the referral date, has there been any litigation with respect to the property?
No.
Yes (Provide details below and attach a copy of each complaint and final disposition, if
any).
Title and Type
Index No. Plaintiff's
Defendant's
of Action
and Court Attorney
Attorney
Disposition or Current Status
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21.
HPD Litigation: Since the referral date, has HPD been a plaintiff or defendant in any litigation with
respect to the property?
No.
Yes (Provide details below).
Title and Type
Index No. Plaintiff's
Defendant's
of Action
and Court Attorney
Attorney
Disposition or Current Status
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22.
Coercion: From the referral date to the present, has any title holder or lessee, 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 a dwelling unit at the property?
No.
Yes (Provide details).
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23.
Services: From the referral date to the present, has any title holder or lessee, its agents,
employees or other persons acting on its behalf interrupted or discontinued any services at the
property, including, but not limited to, heat, hot water, cold water, electricity, gas, and elevator
service?
No.
Yes (Provide details).
24.
Vacate Orders: Has any governmental agency issued any vacate orders with respect to all or part
of the property since the referral date?
No.
Yes (Provide details below and attach certified copies of each vacate order).
Issuing Agency:
HPD
Department of Buildings
Fire Department
Department of Health and Mental Hygiene
Other (Identify): ________________________________________________
Date Issued: ________________________________________________________
Date Lifted: _________________________________________________________
Basis of Order: ______________________________________________________
Number of Occupants Displaced: ________________________________________
Number of Occupants Relocated By HPD: _________________________________
Number of Occupants Currently In HPD Relocation: _________________________
Describe any other relevant information: __________________________________
___________________________________________________________________
___________________________________________________________________
25.
Emergency Repairs: Has HPD performed emergency repairs at the property since the referral
date?
No.
Yes (Provide details below).
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26.
Locks: From the referral date to the present, has any title holder or lessee, its agents, employees
or other persons acting on its behalf removed the possessions of an occupant from the dwelling
unit, removed the door at the entrance to an occupied 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?
No.
Yes (Provide details).
27.
Other: Provide any other information relevant to this application.
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Consent to Access: The owner of the property hereby consents to access by HPD to the property that is
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 HPD makes a final
determination with respect to the grant or denial of the certification pursuant to this application.
Failure to provide such access when requested will prevent the processing of this application and may, in
the discretion of HPD, cause denial of the issuance of a certification.
If this application contains any false or misleading statements, or material omissions, the application may
be denied.
____________________________________
Applicant's Signature
_________________________________________
Applicant's Signature
____________________________________
Print Name Above
_________________________________________
Print Name Above
____________________________________
Relationship to the Property
_________________________________________
Relationship to the Property
____________________________________
Access Authorizer's Signature
_________________________________________
Access Authorizer's Signature
_____________________________________
Print Name Above
_________________________________________
Print Name Above
_____________________________________
Relationship to the Property
_________________________________________
Relationship to the Property
Sworn to this _______ day of
___________, 200__.
_________________________
Notary
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