NOTICE TO TENANT:
If you have lost income or had increased costs during the COVID-19 pandemic, or
moving would pose a significant health risk for you or a member of your household due
to an increased risk for severe illness or death from COVID-19 due to an underlying
medical condition, and you sign and deliver this hardship declaration form to your
landlord, you cannot be evicted until at least May 1, 2021 for nonpayment of rent
or for holding over after the expiration of your lease. You may still be evicted for
violating your lease by persistently and unreasonably engaging in behavior that
substantially infringes on the use and enjoyment of other tenants or occupants or
causes a substantial safety hazard to others.
If your landlord has provided you with this form, your landlord must also provide
you with a mailing address and e-mail address to which you can return this form. If
your landlord has already started an eviction proceeding against you, you can return
this form to either your landlord, the court, or both at any time. You should keep a
copy or picture of the signed form for your records. You will still owe any unpaid
rent to your landlord. You should also keep careful track of what you have paid and
any amount you still owe.
For more information about legal resources that may be available to you, go to
www.nycourts.gov/evictions/nyc/ or call 718-557-1379 if you live in New York City
or go to www.nycourts.gov/evictions/outside-nyc/ or call a local bar association or
legal services provider if you live outside of New York City. Rent relief may be
available to you, and you should contact your local housing assistance office.
Index Number (if known/applicable):
County and Court (if known/applicable):
TENANT’S DECLARATION OF HARDSHIP
DURING THE COVID-19 PANDEMIC
I am a tenant, lawful occupant, or other person responsible for paying rent, use
and occupancy, or any other financial obligation under a lease or tenancy agreement
at (address of dwelling unit):
YOU MUST INDICATE BELOW YOUR QUALIFICATION FOR EVICTION
PROTECTION BY SELECTING OPTION “A” OR “B”, OR BOTH.
A. I am experiencing financial hardship, and I am unable to pay my rent or
other financial obligations under the lease in full or obtain alternative
suitable permanent housing because of one or more of the following:
1. Significant loss of household income during the COVID-19 pandemic.
2. Increase in necessary out-of-pocket expenses related to performing
essential work or related to health impacts during the COVID-19 pandemic.
3. Childcare responsibilities or responsibilities to care for an elderly,
disabled, or sick family member during the COVID-19 pandemic have
negatively affected my ability or the ability of someone in my household
to obtain meaningful employment or earn income or increased my
necessary out-of-pocket expenses.
4. Moving expenses and difficulty I have securing alternative housing
make it a hardship for me to relocate to another residence during the
COVID-19 pandemic.
5. Other circumstances related to the COVID-19 pandemic have negatively
affected my ability to obtain meaningful employment or earn income
or have significantly reduced my household income or significantly
increased my expenses.
To the extent that I have lost household income or had increased expenses, any
public assistance, including unemployment insurance, pandemic unemployment
assistance, disability insurance, or paid family leave, that I have received since the
start of the COVID-19 pandemic does not fully make up for my loss of household
income or increased expenses.
B. Vacating the premises and moving into new permanent housing would
pose a significant health risk because I or one or more members of my
household have an increased risk for severe illness or death from COVID-19
due to being over the age of sixty-five, having a disability or having an
underlying medical condition, which may include but is not limited to
being immunocompromised.
I understand that I must comply with all other lawful terms under my tenancy,
lease agreement or similar contract. I further understand that lawful fees, penalties or
interest for not having paid rent in full or met other financial obligations as required
by my tenancy, lease agreement or similar contract may still be charged or collected
and may result in a monetary judgment against me. I further understand that my
landlord may be able to seek eviction after May 1, 2021, and that the law may provide
certain protections at that time that are separate from those available through this
declaration.
Signed:
Printed name:
Date signed:
NOTICE: You are signing and submitting this form under penalty of law. That
means it is against the law to make a statement on this form that you know is false.
