Form Ra 93 Opd – Fill Out and Use This PDF

This petition may be filed only when the owner has previously served the tenant with an Income Certification Form (DHCR Form RA-93CF) on or before May 1 of the year in which this petition is being filed and 1) the tenant has failed to return the Income Certification Form, or 2) the tenant has returned the Income Certification Form and the owner disputes the total annual income stated by the tenant, or 3) the tenant has returned the Income Certification Form and concedes therein that the total annual income exceeded $200,000.00 in each of the two preceding calendar years. If any of these conditions are met, the owner may petition the Division of Housing and Community Renewal (DHCR) for a determination that the housing accommodation identified below qualifies for high income rent deregulation, which exempt from rent regulation housing accommodations having a "legal regulated rent" (rent stabilized) or "maximum rent" (rent controlled) of $2,500.00 or more per month and which are occupied by persons who have a total annual income in excess of $200,000.00 in each of the two preceding calendar years. Total annual income does not include the annual incomes of bona fide employees of occupants residing in the housing accommodation in connection with such employment or the annual incomes of bona fide subtenants in occupancy pursuant to Section 226-b of the Real Property Law. Owners may petition on this form for a determination of whether the housing accommodation identified below qualifies for deregulation based upon the above criteria. If the housing accommodation is found to qualify for exemption after DHCR's processing of this petition, DHCR will issue an order deregulating the housing accommodation. An original and one copy of this petition must be filed with DHCR no later than June 30th of each year. A petition that is filed late will be dismissed.

An owner receiving J-51 or 421-a tax benefits is ineligible to file for High Income Rent Deregulation until after such benefits expire.

					Part I
					GeneralInformation
A. MailingAddressofTenant(s):							B. MailingAddressofOwner:
Name:							Name:
Number/Street:				Apt. No.:			Number/Street:
City,							City,
State, Zip Code:							State, Zip Code:
BuildingM.D.R.Number:							Telephone No.:

(Name of Owner if different from above.)

C. Subject Building (if different from tenant's mailing address):

Number and Street

Apartment Number

City, State, Zip Code

PartII

ThePetition

D. Check the Appropriate Box

The owner petitions DHCR to issue an order deregulating the housing accommodation based on the tenant's admission in the attachedIncome Certification Form that the total annual household income exceeded $200,000.00 in each of the two preceding calendar years.

The owner contests the household income stated by the tenant(s) in the attached Income Certification Form and requests verification.

The owner requests verification of the household income because the tenant failed to properly return the Income Certification Form to the owner. Proof of service of the ICF is attached.

RA-93 OPD (12/13)

-1-

E.The housing accommodation is subject to the:

	NYCRentStabilizationLaw(CityRentStabilization)			Emergency Tenant Protection Act (State Rent Stabilization)
	NYCRentandRehabilitationLaw(CityRentControl)			Emergency Housing Rent Control Law (State Rent Control)
	An owner receiving J-51 or 421-a tax benefits is ineligible to file for High Income Rent Deregulation until after such benefits
	expire.
F.	Indicate the monthly legal regulated or maximum			Indicate the basis for rent change between dates:
	rent on each of the following dates: (See instructions)
	__________________	$	____________________	____________________________________________________
	Date Petition signed
	April 1, 20______	$	___________________	____________________________________________________
	April 1, 20______	$	___________________	____________________________________________________
	April 1, 20______	$	___________________	____________________________________________________
	April 1, 20______	$	___________________	____________________________________________________
	April 1, 20______	$	___________________	____________________________________________________

G.The tenant(s) named on the lease or otherwise occupying the housing accommodations, if not named in Part I of this Petition, is (are):

H.If there is any other person(s) who, although not named on the lease or not listed as such by the tenant on the attached Income Certification Form, occupies the housing accommodation as a primary residence on other than a temporary basis, enter the name(s) of such person(s) and explain the basis for your belief. Attach additional sheets if necessary.

I.If you dispute the status of any person who may be listed by the tenant on the attached Income Certification Form as either a bona fide employee of the tenant residing in the housing accommodation in connection with his or her employment, or as a bona fide subtenant, list his or her name, and give the grounds upon which you dispute such status. Attach additional sheets if necessary.

J.Date on which the tenant(s) began occupancy of the housing accommodation:

PartIII

Affirmation

(Does not require notarization.)

I have read the information on this form, and I affirm the contents to be true to my own knowledge or information and belief.

Date	Signature of Owner/Agent
	Print Name
RA-93 OPD (12/13)	-2-

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