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- Form DSS-7S "Request for a Modification to Your Cityfheps Rental Assistance Supplement Amount" - New York City (Chinese)
Form DSS-7S "Request for a Modification to Your Cityfheps Rental Assistance Supplement Amount" - New York City (Chinese)
Download Form DSS-7S "Request for a Modification to Your Cityfheps Rental Assistance Supplement Amount" - New York City (Chinese)
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3DSS-7s (TC) 07/02/2020 (page 1 of 3)
(E) 04/10/2020
LLF
CityFHEPS 房租援助補助金額調整申請
(Traditional Chinese)
若您的收入已有所變動，且您正尋求調整 CityFHEPS 房租援助補助金額，請填妥此表格。
第 1 節：租戶資訊
名字：
姓氏：
地址：
公寓/房間
號碼：
城市
州
郵遞區號：
第 2 節：收入變動資訊
我的家庭收入：
已增加
已減少
已無收入
請說明您收入變動的原因：
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
第 3 節：目前收入概述
請填妥下列欄位。包括與您同住且目前有收入的每位人士。包括對方姓名、收入來源（例如：
工作、社會安全生活補助金 [Supplemental Security Income, SSI]、失業保險福利等），以及
對方的每月收入總額。
家庭成員
收入來源
每月總額
（翻頁）
DSS-7s (TC) 07/02/2020 (page 1 of 3)
(E) 04/10/2020
LLF
CityFHEPS 房租援助補助金額調整申請
(Traditional Chinese)
若您的收入已有所變動，且您正尋求調整 CityFHEPS 房租援助補助金額，請填妥此表格。
第 1 節：租戶資訊
名字：
姓氏：
地址：
公寓/房間
號碼：
城市
州
郵遞區號：
第 2 節：收入變動資訊
我的家庭收入：
已增加
已減少
已無收入
請說明您收入變動的原因：
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
第 3 節：目前收入概述
請填妥下列欄位。包括與您同住且目前有收入的每位人士。包括對方姓名、收入來源（例如：
工作、社會安全生活補助金 [Supplemental Security Income, SSI]、失業保險福利等），以及
對方的每月收入總額。
家庭成員
收入來源
每月總額
（翻頁）
DSS-7s (TC) 07/02/2020 (page 2 of 3)
Department of Social Services
(E) 04/10/2020
Human Resources Administration
LLF
第 4 節：文件
請在隨附此填妥表格一同提交的證明文件旁打勾 ()。
證明文件
薪資單
就業信函
SSI 或社會安全傷殘補助 (Social Security Disability, SSD) 發放信函
失業保險福利信函
其他
第 5 節：CityFHEPS 最高租金增加
如果您的房東增加了每年租金，HRA 可以將補貼增加到您家庭規模的最高每年租金。
請輸入新的每年租金金額： $
您必須提交含新租金金額的已簽名租約以及此填妥的申請表。
第 6 節：證明
本人依據僞證懲處條例，聲明本表格所作的所有陳述以及提交的所有文件，在本人所知範圍
內，均屬正確完整。本人保證，一旦簽署本表格，即表示本人同意紐約市人力資源管理局
(Human Resources Administration, HRA) 進行調查，藉此證實或確認本人所提交的資訊，同
時決定本人申請 CityFHEPS 房租援助補助金額調整的適用資格。
簽名
日期
（翻頁）
DSS-7s (TC) 07/02/2020 (page 3 of 3)
Department of Social Services
(E) 04/10/2020
Human Resources Administration
LLF
第 7 節：提交方式
請使用下列其中一種方式來提交您已填妥的表格及證明文件：
raprenewals@hra.nyc.gov
電子郵件：
親自辦理： 109 East 16th Street, 1st Floor, Room 102
New York, NY 10003
_________
_________
位於
與
之間
您是否有醫療或心理健康疾病或殘障問題？此問題是否使得您難以瞭解此通知或完成此通知所
要求事情？此問題是否使您難以取得 HRA 提供的其他服務？我們可助您一臂之力。致電
212-331-4640 聯絡我們。您也可以前往 HRA 辦公室尋求協助。根據法律，您有權尋求此類
協助。
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DD Form 2813
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DD Form 2977 "Deliberate Risk Assessment Worksheet"
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DD Form 1750 "Packing List"
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