Drie Renewal Application Form – Fill Out and Use This PDF

Instructions: Use this form if you are presently receiving a DRIE benefit and are recertifying your eligibility for the DRIE benefit. You are required torecer- tify your eligibility for DRIE benefits at the end of your benefit period on your DRIE order. Please forward the completed, signed application and all necessary documentstotheaddressabove. Seethereverseforfurtherdetailsregardingrequireddocuments.Besuretoanswerallrequiredquestionsonthisform.

SECTIONI - APPLICANTINFORMATION

1.	DRIE ID: __________________________________ 2. Social Security Number:_________________________________
3.	Name of Applicant
	with a Disability: a. ____________________________________ b. _________________________________________
		FIRST NAME	LAST NAME
4.	Address: __________________________________________________________________ 5. Apt. #: ______________
	NUMBER	STREET NAME
6.	Borough: __________________________________________________		7. Zip Code: ___________________________
8.	Daytime Phone Number: (____)_____________________ 9. Email Address: ___________________________________

Rent Stabilized tenants only: Please specify the term of your renewal lease below and attach the fully signed lease(s) to this form.

If your landlord refused to provide you with a renewal lease,please complete the Certification by DRIE RenewalApplicant Without

aRenewalLease and attach it to this renewal form instead. Skip to Section IIif you do not live in a rent-stabilized apartment.

10. LeaseTermoftheRenewal: ❑1Year ❑2Years ❑Landlordrefusedtoprovidearenewallease (Please attach signed Certification)

SECTIONII - ELIGIBILITYINFORMATION

You must provide proof of all disability benefits and other household income for the calendar year preceding the effective date of your DRIE renewal order. Please attach all income and benefit documents to this renewal form.

1.How many people reside in the household? _______________________

2.How many people in the household receive income of any kind (work, benefits, etc.)? _____________________________

3.Please indicate the total/aggregate household income for the previous year: $____________________________

Household income includes but is not limited to SSI/SSDI/VAbenefits, wages, and other income reported on 1099 statements and federal tax returns.

4. Are you receiving any of the following benefits? (Check all that apply)

❑ Supplemental Security Income (SSI)

❑ Social Security Disability Insurance (SSDI)

❑VADisability Pension or VACompensation benefits ❑ Disability-related Medicaid and have received either SSI or SSDI in the past

5. DoyoureceiveSection8oranyotherfederalhousingsubsidy? ❑ Yes ❑ No (If “Yes,” please attach documentation of the benefit.)

SECTIONIII - CERTIFICATION

IherebyaffirmunderpenaltiesprovidedbylawthatIhaveexaminedthisapplicationandtheaccompanyingdocuments,and,to the best of my knowledge and belief, the information provided herein is true, correct and complete.

I understand and agree that if I fail to disclose all household income, including income of tenants (family or non-family), I may be held responsible to repay the City the full amount of any DRIE benefits received improperly plus any interest charges.

Iauthorizethereleaseofmyinformationtootheragenciesforthepurposeofdeterminingmyeligibilityforotherentitlementsorbenefits.

I authorize the Department of Finance to review my state and federal income tax returns to verify my income.

____________________________________________________________	______________________________________
Signature of Applicant with a Disability	Date
____________________________________________________________	______________________________________
Signature of Preparer (If other than applicant)	Date

(SEEREVERSEFORMOREINFORMATION)	DRIE Renewal/Recert. Rev. 02.13.12