Fillable COVID Rent Relief Program: Tenant Rent Attestation Please (New York State)

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COVID Rent Relief Program: Tenant Rent Attestation Please (New York State)

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The COVID Rent Relief Program: Tenant Rent Attestation Please (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 Rent Attestation
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). This is
my primary residence.
I attest that I pay ____________________ ($ amount of rent) in rent each _______________
(frequency of rental payments: month, week, or day) for my residence at
_____________________________________________________________ (address).
The name of the landlord/management company I pay my rent to is,
_________________________________________ (name of landlord or management company).
I send my rent to,
________________________________________________________________________
(landlord/management company’s street address or P.O. Box, city, state and zip code). The
landlord/management company’s telephone number is, _____________________________
(telephone number). The landlord/management company’s email address is,
_________________________________ (this field is optional).
2
__________________________________ ____________________
Tenant Date
Certification:
I hereby affirm under the penalties provided by law that the statements within this
application are true, correct, and complete to the best of my knowledge.
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COVID Rent Relief Program: Tenant Rent Attestation Please (New York State)

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Completed 4 January 2021

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