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Security Voucher: Form W-147N (Front) Rev. 11/2/16

This security voucher guarantees that the Human Resources Administration (HRA) will pay up to one month's rent if a tenant fails to pay rent or damages an apartment. The landlord must submit proof of unpaid rent or damages within three months of the tenant vacating. HRA will only pay if a claim is submitted on time and documentation confirms unpaid rent or damages. The landlord acknowledges acceptance of the voucher in lieu of a cash security deposit by signing.

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393 views2 pages

Security Voucher: Form W-147N (Front) Rev. 11/2/16

This security voucher guarantees that the Human Resources Administration (HRA) will pay up to one month's rent if a tenant fails to pay rent or damages an apartment. The landlord must submit proof of unpaid rent or damages within three months of the tenant vacating. HRA will only pay if a claim is submitted on time and documentation confirms unpaid rent or damages. The landlord acknowledges acceptance of the voucher in lieu of a cash security deposit by signing.

Uploaded by

Wildenis Corona
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Form W-147N (front)

Rev. 11/2/16

Date:
Case Number:
Case Name:
Center:

Security Voucher
This security voucher guarantees that the Human Resources Administration (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 damage to it. The landlord
must submit proof of the unpaid rent and/or damage 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 tenant has vacated the apartment and a review of the documentation submitted by the
landlord confirms that the tenant failed to 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.

The Human Resources Administration (HRA) does not issue cash security deposits. Instead, the Agency is issuing this Security
Voucher. Please be advised that refusal to accept this voucher in lieu of a security deposit may constitute source of income
discrimination under the NYC Human Rights Law Sec. 8-107(5)(a)(1)-(2).

This Security Voucher is issued by the New York City Department of Social Services (NYCDSS), having its principal offices at
150 Greenwich Street, New York, NY 10007, 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.

City: State: Zip:

regarding the participant/tenant listed below:

Participant/tenant:

This Security Voucher is being issued pursuant to Social Services Law Sec. 143-c and 18 NYCRR 352.6 and 381.3, to secure the
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 $ .
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):

Landlord's/Authorized Agent's Signature: Date:


(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: Date:

Control Unit Supervisor's Name (Print):

Control Unit Supervisor's Signature: Date:

Control Unit Authorization #:


Form W-147N (back) Human Resources Administration
Rev. 11/2/16 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 Apt. on or about and occupied the
address 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:

Tenant/Participant defaulted on payment of rent for (provide court


judgment, stipulation, landlord breakdown, etc). Month/Year

Tenant/Participant caused the following damages to the apartment. (Describe and also include proof of
damage[s]: e.g., photographs, estimates, receipts for repairs, etc.)

"I, , hereby swear/affirm, under penalty of perjury, that the information I have given above is
true and complete.

(Signature of Landlord or Office of Corporation)


(Print Name)

Subscribed and sworn to/affirmed before me this (Date)


(Signature)
(Notary Seal)"
Please submit the following items along with this claim form:
z proof of ownership (of the premises); and
z 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.O. Box 02 – 9121
Brooklyn GPO
Brooklyn, NY 11202-9914
For Office of Central Processing use Only

Case Name: Last: First:


Pick-up Code:
Special Roll ─ 1 Job Center:
Case Number: Suffix:

Date Form Prepared: / / Authorization Number


Amount From: To: Restricted Indicator
Issuance Code Dollars Cents Month Day Year Month Day Year

Print Dollar Amount in Words


Dollars Cents

Optional Fields(Block Print Only)


Payee Name:
Address:
City: State: Zip:

Authorized Signature Print Name

Title: Date:
OCP Control Clerk: Date:
OCP CRT Operator: Date:

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