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Get NY DHCR RA-23.5 2020-2024

Signature s of Tenant s See definitions on reverse side of this form RA-23. 5 9/11 INTERNET Date Disabled Person Family Member s Renewal Lease and Eviction Protection Rights 1. Gertz Plaza 92-31 Union Hall St* Jamaica NY 11433 718 739-6400 State of New York Division of Housing and Community Renewal Office of Rent Administration Notice To Owner Of Family Members Residing With The Named Tenant In The Apartment Who May Be Entitled To Succession Rights/Protection From Eviction Please check appropriate box below Notice Requested By Owner Notice Submitted By Tenant Mailing Address of Tenant Tenant s Name Owner s/Agent s Name Number/Street Apt. No* City State Zip Code Subject Building if different from tenant s mailing address For the purpose of determining the right of a family member to a renewal lease or protection from eviction pursuant to rent regulations as described on the reverse side of this form the information below may be requested by owners or provided by tenants as follows by owners of rent stabilized apartments at any time but no more often than once in twelve months by tenants of rent stabilized and rent controlled apartments at any time. The following information may be requested by owners or provided by tenants the name of any person s other than the named tenant s who are residing in the apartment whether such person is a family member of the tenant and if such person is or upon the passage of the applicable period of required minimum residency may become a person entitled to be named as a tenant on a renewal lease for rent stabilized apartments or protection from eviction for rent controlled apartments and the date such person commenced primary residence with the tenant The tenant must provide the owner with the name of any person who has the right to be named as a tenant on a renewal lease whether or not the owner requests the information* A statement of general rights and obligations of tenants and owners including renewal lease rights of stabilized tenants can be found in the Rent Stabilization Lease Rider For Apartment House Tenants Residing In New York City or in DHCR Fact Sheets. Instructions For Tenant When a tenant provides a completed copy of this form to the owner the tenant should obtain and keep proof thereof including a completed copy of the form* The owner should also keep a completed copy of the form* A family member seeking to establish the right to a renewal lease or to protection from eviction upon the vacancy of the tenant may point to the submission of this form to show that this information was given to the owner. This may provide some evidence of the family member s succession rights however an owner may later challenge the statements made in this form* Moreover an owner may use the information in this form if any later statements are inconsistent with the statements made in this form* Statement of Tenant Names of persons other than tenant s residing in the apartment. Date of commencement of primary residence in the apartment by such persons. Family relationship if any If relationship is not listed under 3 a i on reverse side but meets the requirements of 3 a ii indicate other family member or OFM.

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