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Get NY DHCR RA-23.5 2011

Elationship,* 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"). Check box if such persons are senior citizens and/or disabled persons. Senior Citizen* 1. 2. 3. 4. For additional persons, check box and attach separate sheet. 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 .

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