Form DSS-14 "Special Supplemental Assistance Fund Claim Request Form" - New York City

What Is Form DSS-14?

This is a legal form that was released by the New York City Department of Social Services - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 27, 2020;
  • The latest edition provided by the New York City Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DSS-14 by clicking the link below or browse more documents and templates provided by the New York City Department of Social Services.

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Download Form DSS-14 "Special Supplemental Assistance Fund Claim Request Form" - New York City

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DSS-14 (E) 05/27/2020
Special Supplemental Assistance Fund Claim Request Form
Instructions: Landlords can claim up to $3,000 dollars in expenses that occurred during the duration of the tenancy
(CityFHEPS, SEPS, LINC, and CITYFEPS rental assistance program only) provided that the expenses cannot
already be covered by other programs such as the security deposit or emergency arrears. Please submit along with
this claim form:
• Proof of ownership (of premises); and
• 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.)
A. PROPERTY INFORMATION
Landlord Name:
Tenant Name:
Lease Start Date:
Tenant Address:
B. AMOUNT REQUESTED AND TYPE OF CLAIM REQUEST
Total Amount Requested:
Date Submitted:
Check Made Payable To:
Mailing Address:
Reason for Claim
Tenant defaulted on payment of rent for _________ months/year (provide court
(complete the following):
judgment, stipulation, landlord breakdown, etc.
Tenant caused damages to the apartment.
C. AFFIRMATION
I ______________________________, hereby swear/affirm, under penalty of perjury, that the information I have
given above is true and complete. By signing below, I am agreeing to provide any necessary documents
requested by HRA beyond those that have been included in this claims request.
_______________________________ _________________________________________ _______________
Landlord:
Print Name
Signature
Date
Subscribed and sworn to/affirmed before me
this _______ day of ___________, 20______.
Notary’s Signature ______________________________________
Notary Seal:
Send Claim to:
Email: SSAF@hra.nyc.gov
Fax:
917 639-0366
Mail:
Rental Assistance Program Unit, 109 East 16th Street, 10th Floor, New York, NY 10003
AGENCY USE ONLY
Request Outcome:
Total Amount Approved:
Tenant Name:
Case Number:
Submitted by:
Date:
Approved by:
Date:
DSS-14 (E) 05/27/2020
Special Supplemental Assistance Fund Claim Request Form
Instructions: Landlords can claim up to $3,000 dollars in expenses that occurred during the duration of the tenancy
(CityFHEPS, SEPS, LINC, and CITYFEPS rental assistance program only) provided that the expenses cannot
already be covered by other programs such as the security deposit or emergency arrears. Please submit along with
this claim form:
• Proof of ownership (of premises); and
• 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.)
A. PROPERTY INFORMATION
Landlord Name:
Tenant Name:
Lease Start Date:
Tenant Address:
B. AMOUNT REQUESTED AND TYPE OF CLAIM REQUEST
Total Amount Requested:
Date Submitted:
Check Made Payable To:
Mailing Address:
Reason for Claim
Tenant defaulted on payment of rent for _________ months/year (provide court
(complete the following):
judgment, stipulation, landlord breakdown, etc.
Tenant caused damages to the apartment.
C. AFFIRMATION
I ______________________________, hereby swear/affirm, under penalty of perjury, that the information I have
given above is true and complete. By signing below, I am agreeing to provide any necessary documents
requested by HRA beyond those that have been included in this claims request.
_______________________________ _________________________________________ _______________
Landlord:
Print Name
Signature
Date
Subscribed and sworn to/affirmed before me
this _______ day of ___________, 20______.
Notary’s Signature ______________________________________
Notary Seal:
Send Claim to:
Email: SSAF@hra.nyc.gov
Fax:
917 639-0366
Mail:
Rental Assistance Program Unit, 109 East 16th Street, 10th Floor, New York, NY 10003
AGENCY USE ONLY
Request Outcome:
Total Amount Approved:
Tenant Name:
Case Number:
Submitted by:
Date:
Approved by:
Date:

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