Form DSS-7S "Request for a Modification to Your Cityfheps Rental Assistance Supplement Amount" - New York City

What Is Form DSS-7S?

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 April 10, 2020;
  • The latest edition provided by the New York City Department of Social Services;
  • Easy to use and ready to print;
  • Available in Chinese;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DSS-7S 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-7S "Request for a Modification to Your Cityfheps Rental Assistance Supplement Amount" - New York City

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DSS-7s (E) 04/10/2020 (page 1 of 3) LLF
Request for a Modification to Your CityFHEPS Rental Assistance
Supplement Amount
Complete this form if your income has changed and you are seeking a modification to your
CityFHEPS rental assistance supplement amount.
Section 1: Tenant Information
First Name:
Last Name:
Address:
Apartment/Room
Number:
City
State
Zip Code:
Section 2: Income Change Information
My household income has:
Increased
Decreased
Ended
Please explain why your income has changed:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Section 3: Current Income Summary
Complete the fields below. Include each person who lives with you that currently receives
income. Include their name, the income source (for example: job, Supplemental Security
Income [SSI], Unemployment Insurance Benefits), and their total monthly income.
Household Member
Income Source
Monthly Total
(Turn Page)
DSS-7s (E) 04/10/2020 (page 1 of 3) LLF
Request for a Modification to Your CityFHEPS Rental Assistance
Supplement Amount
Complete this form if your income has changed and you are seeking a modification to your
CityFHEPS rental assistance supplement amount.
Section 1: Tenant Information
First Name:
Last Name:
Address:
Apartment/Room
Number:
City
State
Zip Code:
Section 2: Income Change Information
My household income has:
Increased
Decreased
Ended
Please explain why your income has changed:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Section 3: Current Income Summary
Complete the fields below. Include each person who lives with you that currently receives
income. Include their name, the income source (for example: job, Supplemental Security
Income [SSI], Unemployment Insurance Benefits), and their total monthly income.
Household Member
Income Source
Monthly Total
(Turn Page)
DSS-7s (E) 04/10/2020 (page 2 of 3)
Department of Social Services
LLF
Human Resources Administration
Section 4: Documents
Place a check mark (✓) next to the supporting documents you will submit with this completed
form.
Supporting Documents
Pay stubs
Employment letter
SSI or Social Security Disability (SSD) award letter
Unemployment Insurance Benefits letter
Other
Section 5: Increased CityFHEPS Rent Maximum
If your landlord has increased your annual rent, HRA can increase your subsidy up to the
annual maximum rent for your household size.
Please enter your new annual rent amount: $
You must submit a signed lease with the new rent amount with this completed
application.
Section 6: Attestation
I declare under penalty of perjury that all statements made on and documents submitted with
this form are correct and complete to the best of my knowledge. I certify that by signing this
form, I agree to an investigation conducted by the New York City Human Resources
Administration (HRA) to verify or confirm the information I have submitted and determine my
eligibility for a modification to my CityFHEPS rental assistance supplement amount.
Signature
Date
(Turn Page)
DSS-7s (E) 04/10/2020 (page 3 of 3)
Department of Social Services
LLF
Human Resources Administration
Section 7: Submission Options
Please use one of the options below to submit your completed form and supporting
documents:
Email:
raprenewals@hra.nyc.gov
In-Person: 109 East 16th Street, 1st Floor, Room 102
New York, NY 10003
Between
and
_________
_________
Do you have a medical or mental health condition or disability? Does this condition
make it hard for you to understand this notice or to do what this notice is asking? Does this
condition make it hard for you to get other services at HRA? We can help you. Call us at
212-331-4640. You can also ask for help when you visit an HRA office. You have a right to
ask for this kind of help under the law.
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