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Get Hra Security Voucher Form 2011

Form W-147N front Rev. 1/24/11 Date Case Number Case Name Center Security Voucher The Human Resources Administration HRA no longer issues cash security deposits. Landlord please acknowledge your acceptance of the Security Voucher in lieu of a cash security deposit by signing this form below Landlord s/Authorized Agent s Name print This voucher is not valid until it has been fully completed and authorized in the For HRA Use Only section below. For HRA Use Only Supervisor s Name Print Supervisor s Signature Control Unit Supervisor s Name Print Control Unit Authorization Form W-147N back Human Resources Administration Family Independence Administration Landlord s Claim for Security Voucher Payment I we the Landlord s of the premises described on page 1 of this form certify that tenant/participant name has vacated the apartment located at on or about and occupied the date apartment within three months prior to the date of this certification. I hereby request that the security voucher be paid to me for the reason specified below c d e f g Tenant/Participant defaulted on payment of rent for provide court Month/Year judgment stipulation landlord breakdown etc. Instead the Agency is issuing this Security Voucher. This voucher guarantees that HRA will pay up to the equivalent of one month s rent if it is verified that the tenant who occupied the apartment failed to pay his/her rent and/or caused damages to it. The landlord must submit proof of the unpaid rent and/or damages along with the Landlord s Claim For Security Voucher Payment on the back page within three months after the tenant has vacated the apartment. The Agency will only make a payment if the claim is submitted within three months after the pay his/her rent and/or damaged the apartment. This Security Voucher will not be honored until the front and back pages have been completed signed notarized and returned to HRA. This Security Voucher is issued by the New York City Department of Social Services NYCDSS having its principal offices at 180 Water Street New York NY 10038 to Name of Landlord Landlord s Address City State Zip as Landlord of the premises to be rented to the participant/tenant located at include proof of ownership Address Apt. regarding the participant/tenant listed below Participant/tenant landlord against non-payment of rent and/or damages as a condition of renting the above-identified premises Premises to the above-named Cash Assistance participant/tenant Participant/Tenant. A claim for the payment of this Security Voucher by the landlord must be made after and within three months of the participant/tenant vacating the premises. The claim must be made by the full completion and execution of the Claim on page two of this form and cannot exceed the amount of the Tenant s monthly rent which is. damage s e*g* photographs estimates receipts for repairs etc* I true and complete. hereby swear/affirm under penalty of perjury that the information I have given above is Signature of Landlord or Office of Corporation Print Name Subscribed and sworn to/affirmed before me this Signature Notary Seal Please submit the following items along with this claim form proof of ownership of the premises and documentation of unpaid rent e*g* court judgment or stipulation landlord breakdown etc* or documentation to verify the damage s to the apartment and the cost of repairs e*g* photographs estimates receipts for repairs etc* Please send claim to Office of Central Processing P.

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