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Application For Certification Of No Harassment Or Exemption (SRO) Form. This is a New York form and can be use in New York Local County.
Tags: Application For Certification Of No Harassment Or Exemption (SRO), New York Local County, New York
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.
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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).
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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