Fillable COVID Rent Relief Program: Tenant/Household Member Employment Attestation (New York State)

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COVID Rent Relief Program: Tenant/Household Member Employment Attestation (New York State)

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The COVID Rent Relief Program: Tenant/Household Member Employment Attestation (New York State) form is 2 pages long and contains:

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1
ANDREW M. CUOMO
Governor
RUTHANNE VISNAUSKAS
Commissioner/CEO
COVID Rent Relief Program: Tenant/Household Member Employment Attestation
Instructions: This form must be completed by each adult member in the household who has lost
income or employment due to COVID-19 and are unable to provide paystubs, W2s, an employer
letter, or any other written documentation of income.
Please note: this form must be completed in English. If you need assistance filling out this
form, including interpretation, please contact (833) 499-0318.
Date: __________________
My name is _________________________________________ (name) and I reside at
_____________________________________________________________ (address).
Prior to the COVID-19 pandemic, I was employed as a:
___________________________________________ (job you performed).
I earned ____________________________________________________ ($ amount of income)
every ________________________ (frequency of earnings: month, week, or day) before taxes
were taken out, if any.
Currently, I am employed as a: ___________________________________________ (job you
perform, or write “unemployed” if you have lost your job).
2
I earn ____________________________________________________ ($ amount of income)
every ________________________ (frequency of earnings: month, week, or day) before taxes
are taken out, if any.
__________________________________ ____________________
Tenant/Household Member Date
Certification:
I hereby certify under penalties provided by law that I currently reside at the address I
provided and that the information provided is true and complete. I understand and agree that
if I fail to disclose all income from household members, I may be held responsible to repay
the State of New York the full amount of any benefits received improperly, plus any
interest charges.
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COVID Rent Relief Program: TenantHousehold Member Employment Attestation (New York State)

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Completed 4 January 2021

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