Form W-146E at a glance
What it is: Form W-146E is the Request to Pay Rent Arrears in Excess of Cash Assistance Maximum Shelter Allowance.
Who signs: The Applicant/Participant signs, and the third party signs.
You are requesting assistance to pay rent arrears to avoid eviction.
What to bring and attach to Form W-146E
To have this request approved, you must provide documentation showing how future rent payments will be made, including a statement from a third party who will help you pay your rent.
A filled-in Form W-146E example: a sister agrees to pay the excess rent
How to fill out Form W-146E, box by box
Request to Pay Rent Arrears
Enter the Date, the Case Number and the Case Name.
Write your Name after I.
You understand that the rent arrears payment will be made in the form of a check made payable to your landlord.
Sign on the Applicant/Participant's Signature line and enter the Date.
Agreement by Third Party to Pay Excess Rent
Under Agreement by Third Party to Pay Excess Rent, the third party writes the Name after I and affirms that.
The third party agrees to pay the excess rent in the amount of $ entered.
Enter the Applicant/Participant's Name, the Applicant/Participant's Address and the date it is effective for the apartment occupied.
Payment made directly to
The payment will be made directly to the: aforementioned applicant/participant or landlord.
For the landlord, enter the landlord (name and address).
Monthly household income and proof of income
The third party affirms that the income is sufficient to meet all of the expenses as well as the excess rent payment.
The third party enters the monthly household income and the shelter expense.
The proof of income is: Pay stubs, W-2 form and/or letter from employer on employer's stationery from the Employer's Name and Address, or the Proof of other income/source.
Relationship, address and signature
Enter the relationship to the applicant/participant and the address.
The third party affirms that the information is true and correct, then signs on the Signature line and enters the Date.
More rules for Form W-146E
If any of the rent arrears advanced to you duplicates assistance previously given to you by the Human Resources Administration, you agree to the recoupment of such portion of the arrears payment.
Common questions about Form W-146E
What is a W 146E form?
Form W-146E is the Request to Pay Rent Arrears in Excess of Cash Assistance Maximum Shelter Allowance. You understand that your rent is in excess of the cash assistance maximum shelter allowance for your household size.
Sources
[1] Form W-146E (Rev. 12/3/09), Request to Pay Rent Arrears in Excess of Cash Assistance Maximum Shelter Allowance, NYC Human Resources Administration (the Official source link on this page).