Form W-147N at a glance
What it is: Form W-147N is a Security Voucher of the Human Resources Administration (HRA).
Who signs: Landlord, acknowledge your acceptance of the Security Voucher in lieu of a cash security deposit by signing the form.
A filled-in Form W-147N example: a landlord accepts the voucher
How to fill out Form W-147N, box by box
The top of the form
The top of the form has boxes for Date, Case Number, Case Name and Center.
The landlord
Enter the Name of Landlord, the Landlord's Address, and the City, State and Zip.
The premises to be rented
Enter the Address, Apt., City, State and Zip of the premises to be rented to the participant/tenant, and include proof of ownership.
The participant/tenant
Enter the participant/tenant in Participant/tenant.
Landlord's acceptance by signing
Print the Landlord's/Authorized Agent's Name, sign the Landlord's/Authorized Agent's Signature line and enter the Date. This voucher is not valid until it has been fully completed and authorized in the "For HRA Use Only" section.
The claim cannot exceed the amount of the Tenant's monthly rent.
For HRA Use Only
The For HRA Use Only section has the Supervisor's Name (Print), Supervisor's Signature and Date, the Control Unit Supervisor's Name (Print), Control Unit Supervisor's Signature and Date, and the Control Unit Authorization #.
Landlord's claim: the tenant who vacated the apartment
Enter the tenant/participant name after "certify that": the landlord of the premises described on page 1 certifies that the tenant/participant has vacated the apartment located at Apt. on or about the date entered, and occupied the apartment within three months prior to the date of this certification.
The reason for the Landlord's Claim
Request payment of the security voucher for the reason specified: Tenant/Participant defaulted on payment of rent for (Month/Year), or Tenant/Participant caused the following damages to the apartment.
Where the tenant defaulted on payment of rent, provide court judgment, stipulation, landlord breakdown, etc; where the tenant caused damages, describe and also include proof of damage[s]: e.g., photographs, estimates, receipts for repairs, etc.
Swearing before a notary
Print the landlord's name after "I," and sign the (Signature of Landlord or Office of Corporation) line to swear/affirm, under penalty of perjury, that the information given is true and complete.
The notary lines are Subscribed and sworn to/affirmed before me this, with the (Date), (Signature) and (Notary Seal).
More rules for Form W-147N
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.
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).
Submit proof of ownership (of the premises), and documentation of unpaid rent or documentation to verify the damage(s) to the apartment and the cost of repairs, along with this claim form.
Common questions about Form W-147N
Is there a deadline?
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.
Where do I file it?
Send the claim to: Office of Central Processing, P.O. Box 02 - 9121, Brooklyn GPO, Brooklyn, NY 11202-9914.
Sources
[1] Form W-147N (Rev. 11/2/16), Security Voucher, NYC Human Resources Administration (the Official source link on this page).