F16

AGREEEMENTTO
OMAINTTAINTENA
ANT
CONTACT
C
TINFORM
MATION

Theunde
ersigned(O
Owner)here
ebyaffirmso
ownershipooftheproperrtylocatedaat:
________
__________
___________
__________
_______________________________________________
PropertyAd
ddress

________
__________
___________
__________
_______________________________________________
City,State,ZZIP

(Propertty).
IherebycertifythattthePropertyycontains__
__rentalunnits,ofwhich
h___arecurrentlyoccu
upied.
Theseun
nitsareoccupiedasfollo
ows:
(Completetthistableforeeachunit/apa
artmentthat iscurrentlyooccupiedbyatenant)

TENANTTINFORMATTION

Unitor
Apt#

Unit
currently
occupied?
Y/N

NameofTenan
nt(HeadofHou
usehold)

Telephone#
(ifavailable)

Iftenanth
hasa
currentleaase,
enterMonth
h/Year
ofleasee
expiratio
on.
Iftenantism
month
tomonth,eenter
N/A

Current
nthly
Mon
Reent

Rev. 1
Aug. 2013
Manual Fill

Furthermore,theinformationavailabletomeaboutanyprevioustenant(s)wholeftbecause
theunitwasnothabitableafterthestormisasfollows:
(Completethistableonlyforeachunit/apartmentthatwasoccupiedatthetimeofHurricaneSandybut
wasvacatedbecausetheunitwasuninhabitableafterthestorm)

TENANTSWHOVACATEDDUETOSTORM
Unitor
Apt#

Name(s)ofPreviousTenant
(HeadofHousehold)

Forwardingaddress
(ifavailable)

Telephone#
(ifavailable)

Whendid
Tenant
leave?
Month/Year

Monthly
rentat
timeof
storm

IacknowledgeandagreethatIamresponsibleforobtainingandretainingcontact
information,including,ataminimum,aresidentialforwardingaddress,foranyandallfor
currentandfuturetenantsthatresideatthePropertyduringthependencyofmyapplication
for,andreceiptof,benefitswiththeNYCBuilditBackprogram.IunderstandthatifIfailto
maintainanaccurateforwardingaddressforanyandalltenantswhovacatethePropertyafter
todaysdate,ImaybedeemedineligibleforbenefitsundertheNYCBuilditBackprogramor
otherprogramrestrictionsmaybeimposed.
IacknowledgethatIhavecarefullyreadthisAgreement,andIrepresentthatIfullyunderstand
itscontentsandsignitvoluntarily.

__________________________________
Owner(PrintName)

__________________________________
AdditionalOwner(PrintName)

__________________________________
AdditionalOwner(PrintName)

__________________________________
AdditionalOwner(PrintName)

____________________________________ ___________________
Date
Signature

____________________________________ ___________________
Date
Signature

____________________________________ ___________________
Date
Signature

____________________________________ ___________________
Date
Signature

Rev. 1
Aug. 2013
Manual Fill