Fillable COVID Rent Relief Extension Program: Appeal Form Instructions: (New York State)

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COVID Rent Relief Extension Program: Appeal Form Instructions: (New York State)

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ANDREW M. CUOMO
Governor
RUTHANNE VISNAUSKAS
Commissioner/CEO
COVID Rent Relief Extension Program: Appeal Form
Instructions: Please use this form to appeal a denial of a COVID Rent Relief Program application or
to appeal the calculation of your subsidy amount. If you believe your application was improperly
denied or that the amount of subsidy you were approved for has been miscalculated, you have seven
(7) business days from the date of the notification of denial or award to submit this appeal form.
You may visit our website, https://hcr.ny.gov/rrp, for more information. Please note, appeals will
not be considered if funding for the COVID Rental Relief Program has been exhausted.
Please complete all sections of this fillable form. You may submit your appeal by:
Uploading your completed Appeal Form and all required documents to this site
https://covidrentreliefappeals.hcr.ny.gov
This Appeal Form and all supporting documents must be submitted together by uploading to the site
listed above. Please make sure that you include all documents that support your appeal, as you will
not be permitted to submit additional documentation.
Please note: This form is translated into Spanish, Chinese, Bengali, Korean, Haitian-Creole and
Russian. Translated forms are available here https://hcr.ny.gov/crrp-translated-appeal-information,
however this form must be completed in English.
1. Applicant Information:
Confirmation Number: ________________________________________________
Name:
Address:
Telephone number:
Email (optional):
You may authorize a caseworker, attorney or other personal representative to submit an appeal for the
COVID Rent Relief Program on your behalf. You may do so by providing the representative’s name,
organization (if applicable), address, telephone number and email address (optional) and then signing
this form. Your Authorized Representative must also sign this form.
See COVID Rent Relief Program: Authorized Representative Release for Appeal Form at the end of this
application (Appendix A). Please note, the Authorized Representative Release Form (Appendix A) must
be completed in English.
2
2. Representative Information (if any):
Name:
Organization:
Address:
Telephone number:
Email (optional):
3. Please select the reason why you are submitting an appeal from the options listed below:
A. I believe I was wrongfully denied assistance:
My primary rental residence is in NYS.
My rental burden was calculated incorrectly.
My income prior to March 1, 2020 was calculated incorrectly
My current income was calculated incorrectly
My income during the coverage period was not the same or more than my income
prior to March 2020
Other
B. I believe the amount of subsidy was calculated incorrectly
4. Please use the space below to explain why you believe HCR’s determination was wrong.
You may also attach additional pages if necessary. You should provide copies of any
written documentation that will further support your claim. (Please do not send any
originals.)
Certification:
I have read the information entered on this application and I affirm that this application to appeal,
to the best of my knowledge, information and belief, is true, accurate and complete. I understand
and agree that the entry of my name below by electronic means constitutes my signing and filing
this application to appeal. I further affirm that I am the tenant of this subject premises, or that I
am the authorized representative of the tenant of said premises and that I am authorized to sign
and file this application with the New York State Division of Housing and Community Renewal.
3
Applicant Date
Appendix A - COVID Rent Relief Program: Authorized Representative Release for Appeal
Date: ________________________________________________________________________
Confirmation #: ________________________________________________________________
Applicant Name: _______________________________________________________________
Applicant Address: _____________________________________________________________
Applicant Telephone Number: ____________________________________________________
Applicant Email Address (optional): _______________________________________________
Instructions: You may authorize a caseworker, attorney or other personal representative to submit an
appeal regarding a determination made by the COVID Rent Relief Program on your behalf. You may
do so by providing the representative’s name, organization (if applicable), address, telephone number
and email address (optional) below and then signing this form. Your Authorized Representative must
also sign this form.
Please note: this form must be completed in English.
Authorized Representative’s Information:
Name: ____________________________________________________________________
Organization (if applicable): ___________________________________________________
Address: ___________________________________________________________________
Telephone Number: __________________________________________________________
Email (optional): ____________________________________________________________
I hereby authorize the above designated individual to act as my representative with regard to the COVID
Rent Relief Program until I revoke this authorization.
I understand that by signing this form, I am authorizing the above designated individual to submit an
appeal of a determination made by the COVID Rent Relief Program; communicate on my behalf with
New York State Homes and Community Renewal and its agent(s) in order to facilitate the processing of
my appeal with the COVID Rent Relief Program.
4
I understand that I may revoke all or part of this authorization at any time by notifying New York State
Homes and Community Renewal in writing by sending via email to covidrentrelief@hcr.ny.gov.
_______________________________________ _____________________
Applicant Date
_______________________________________ _____________________
Authorized Representative Date
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COVID Rent Relief Extension Program: Appeal Form Instructions: (New York State)

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Completed 31 March 2021

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