CPL Article 530, RPL§227-c Application for an Order to Terminate or Sever Lease or Rental Agreement __________________ COURT COUNTY OF ______________ : PART ___ [CITY, TOWN, VILLAGE OF _________________ ] -------------------------------------------------------------------x The People of the State of New York -against________________________, Defendant. APPLICATION FOR AN ORDER TO TERMINATE OR SEVER LEASE OR RENTAL AGREEMENT In the matter of the Application of ________________________, Docket No. _____________ Indictment No. _____________ Lessee/tenant -against________________________, Landlord(s), and/or ________________________, Co-tenant(s). -------------------------------------------------------------------x TO THE ________________ COURT: 1. I am the above captioned lessee/tenant and am applying to this court for an order: G terminating the lease or rental agreement, and/or G severing the co-tenancy at the following address: _________________________________________________. specify address of subject premises, including apartment number, if any 2. I am a person protected by: G an order of protection; G a temporary order of protection; issued by this Court in the above captioned criminal proceeding. The order protects me and/or my children against the above captioned defendant. The order expires on ___________________. specify date 3. The defendant [check all boxes that apply]: G resides in the subject premises; G resided in the subject premises until [specify] ________________; G is named as a tenant or co-tenant on the lease or rental agreement; G is a subtenant of all or part of the subject premises. If so, the primary tenant is ____________________; G is not named in the lease but may have a right or claim to reside in or occupy the subject premises as a result of my having occupied the premises; G none of the above. 1 American LegalNet, Inc. www.FormsWorkflow.com 4. The lease or rental agreement regarding the subject premises [G is] [G is not] the subject of litigation in a housing, matrimonial, criminal or any other proceeding in any other court. [If it is the subject of litigation, specify the court, status of case and docket or index number, if available]: 5. Despite the order or temporary order of protection, I believe that if I remain in the subject premises I and/or my children will remain at substantial risk of physical or emotional harm from the defendant. I believe that if I am permitted to terminate my obligations on this lease or rental agreement, this risk will be substantially reduced. 6. I offer the following facts and circumstances in support of my application: [specify the facts supporting the application, including names and ages of children, if any]: 7. On _______________, I made G an oral G a written request to the landlord/owner to voluntarily specify date consent to terminate my lease or rental agreement, but: G the landlord has not responded to my request; or G the landlord refused to consent on ________________. specify date 8. G I am the only person named on the lease or rental agreement as tenant or lessee. G In addition to me, the following person(s) are named as co-tenants or co-lessees on the lease or rental agreement: ______________________________________________________________; and, specify names of co-tenants or co-lessees a. G The above-named co-tenant(s) or co-lessee(s) have all consented to the termination of the lease or rental agreement. OR b. G The following co-tenant(s) or co-lessee(s) refused to consent to the termination of the lease or rental agreement [specify]: ________________________________. OR c. G The following co-tenant(s) or co-lessee(s) has/have not responded as to the termination of the lease or rental agreement [specify]: ________________________________. 9. In addition to any persons who may have been named in paragraph 8: G there are no other adults 18 or older residing in or occupying the premises. G the following adults 18 and older reside in or occupy the premises. [For each person, state whether s/he has consented to vacate the premises and, if so, when]: G I do not know of anyone 18 or over who has a right or claim to reside in or occupy the premises. G although the following people 18 or older do not reside in or occupy the premises, they may have a right, or claim to have a right, or claim to reside in or occupy the premises. [For each person, state whether s/he 2 American LegalNet, Inc. www.FormsWorkflow.com has waived those possible rights or claims and consented to the termination or severance of the lease]: 10. G I have fully met my obligation to pay rent and other payments due on the lease or rental agreement up to _______________, and will pay all further rent and other payments due from me up until the date specify date specified by this Court for termination of the lease or rental agreement or severance of my obligation. G I have not paid rent or other payments due on the lease or rental agreement since _____________. The specify date following amounts are due and owing to date _________________. I will pay this amount, as well as specify amount owed rent and other payments due from me up until the date specified by this Court for termination of the lease or rental agreement or severance of my obligation as follows: 11. Other than the person against whom the order or temporary order of protection was issued, the leasehold premises: G were delivered to the landlord free of all occupants as of ______________. specify date G will be delivered to the landlord free of all occupants as of ______________. specify date 12. Other than the person against whom the order or temporary order of protection was issued, the leasehold premises: G were left to the co-tenant free of all other occupants as of _________________. specify date G will be left to the co-tenant free of all other occupants as of _________________. specify date 13. No prior application has been made for the relief requested in this motion, except: WHEREFORE, I respectfully request this Court issue an order: G terminating my lease or rental agreement; G severing me from the co-tenancy; and terminating my obligation to pay any rent or other payments on the lease or rental agreement from the date specified by the Court in the order; G sealing this petition, any orders issued by this Court in connection therewith and the record of this proceeding and prohibiting disclosure to anyone not a party to this petition except by order of this Court [state reasons why sealing should be ordered]: And for such other and further relief as the Court may deem just and proper. Signature of Attorney (if any) Signature of Lessee/Tenant Print name Print name Address and Telephone Number Address and Telephone Number Date 3 American LegalNet, Inc. www.FormsWorkflow.com VERIFICATION STATE OF NEW YORK COUNTY OF ) ):ss: ) being duly sworn, says that (s)he is the Lessee/Tenant in the above named proceeding and that the foregoing application is true to (his)(her) own knowledge, except as to matters therein stated to be alleged on information and belief and as to those matters (s)he believes it to be true. ________________________ Lessee/Tenant Sworn to before me this day of . ________________________ (Deputy) Clerk of the Court Notary Public 4 American LegalNet, Inc. www.FormsWorkflow.com