Form IM5357 Attachment 5 "Pre-tenancy Inspection Form" - Onondaga County, New York

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Sarah Merrick
JOANNE M. MAHONEY
COMMISSIONER
COUNTY EXECUTIVE
ONONDAGA COUNTY DEPARTMENT OF SOCIAL SERVICES-ECONOMIC SECURITY
Temporary Assistance Division 421 Montgomery Street Syracuse, NY 13202
*Phone (315) 435-2700
* Fax ( 315) 435-2929 * Fax ( 315) 435-8230
PRE-TENANCY INSPECTION FORM
In an effort to prevent fraudulent activity, OCDSS-ES reserves the right to re-inspect any dwelling prior to Security Agreement authorization.
Tenant/Client Name: _________________________________ Tenant/Client Phone: _____________________________
Landlord Name: _____________________________________ Landlord Phone: _________________________________
Dwelling Address: ___________________________________________________________________________________
STREET
CITY/TOWN
ZIP CODE
Date of Inspection: _________________ Anticipated Move-In Date: __________ Anticipated Monthly Rent: _________
Inspection conducted by:
Landlord & Tenant
Landlord Only
Total number of apartments at this property ? _______________
Has a cash security deposit been received from, or paid on behalf of, the above tenant/client?
Yes
No
At inspection, were the utilities on?
Yes
No
Were smoke and carbon monoxide detectors operational?
Yes
No
Is there a working stove ?
Yes
No
Is there a working refrigerator ?
Yes
No
Directions: Circle the corresponding letter (G=Good, F= Fair, P=Poor, N= Not applicable/ Not accessible by tenant/client household) to
describe the present condition of the items listed below. See the reverse side of this document for guidance on determining condition.
Use
the Comments section to provide a detailed description of all items marked Poor, as well as any information not otherwise captured by the letter system. NOTE:
Future claims will not be paid for damage to any items classified as Poor (with no details provided) or Not applicable.
Summary of Dwelling Condition
General Condition of Unit
Good
Fair
Poor
Level of Cleanliness
Good
Fair
Poor
COMMENTS:
DOCUMENT IS NOT VALID UNLESS REQUIRED SIGNATURES ARE PRESENT AND BOXES CHECKED
Client/ Tenant signature is missing
because_____________________________________________________________________________________________
___________________________________________________________________________________________________
I have read the Notice to Tenant/Client attached to this form
and agree to the terms.
________________________________________________________
_____________________________________________________
Client/Tenant’s Signature
Date
I have read the Notice to Landlord attached to this form and
agree to the terms.
Landlord’s Vendor ID # __________________________
_____________________________________________________
Landlord/Agent’s Signature
Date
IM 5357 FRONT
Sarah Merrick
JOANNE M. MAHONEY
COMMISSIONER
COUNTY EXECUTIVE
ONONDAGA COUNTY DEPARTMENT OF SOCIAL SERVICES-ECONOMIC SECURITY
Temporary Assistance Division 421 Montgomery Street Syracuse, NY 13202
*Phone (315) 435-2700
* Fax ( 315) 435-2929 * Fax ( 315) 435-8230
PRE-TENANCY INSPECTION FORM
In an effort to prevent fraudulent activity, OCDSS-ES reserves the right to re-inspect any dwelling prior to Security Agreement authorization.
Tenant/Client Name: _________________________________ Tenant/Client Phone: _____________________________
Landlord Name: _____________________________________ Landlord Phone: _________________________________
Dwelling Address: ___________________________________________________________________________________
STREET
CITY/TOWN
ZIP CODE
Date of Inspection: _________________ Anticipated Move-In Date: __________ Anticipated Monthly Rent: _________
Inspection conducted by:
Landlord & Tenant
Landlord Only
Total number of apartments at this property ? _______________
Has a cash security deposit been received from, or paid on behalf of, the above tenant/client?
Yes
No
At inspection, were the utilities on?
Yes
No
Were smoke and carbon monoxide detectors operational?
Yes
No
Is there a working stove ?
Yes
No
Is there a working refrigerator ?
Yes
No
Directions: Circle the corresponding letter (G=Good, F= Fair, P=Poor, N= Not applicable/ Not accessible by tenant/client household) to
describe the present condition of the items listed below. See the reverse side of this document for guidance on determining condition.
Use
the Comments section to provide a detailed description of all items marked Poor, as well as any information not otherwise captured by the letter system. NOTE:
Future claims will not be paid for damage to any items classified as Poor (with no details provided) or Not applicable.
Summary of Dwelling Condition
General Condition of Unit
Good
Fair
Poor
Level of Cleanliness
Good
Fair
Poor
COMMENTS:
DOCUMENT IS NOT VALID UNLESS REQUIRED SIGNATURES ARE PRESENT AND BOXES CHECKED
Client/ Tenant signature is missing
because_____________________________________________________________________________________________
___________________________________________________________________________________________________
I have read the Notice to Tenant/Client attached to this form
and agree to the terms.
________________________________________________________
_____________________________________________________
Client/Tenant’s Signature
Date
I have read the Notice to Landlord attached to this form and
agree to the terms.
Landlord’s Vendor ID # __________________________
_____________________________________________________
Landlord/Agent’s Signature
Date
IM 5357 FRONT
Attachment #5
PRE-TENANCY INSPECTION FORM
Notice to Client/Tenant
Please read before signing
I hereby state that the property was inspected before moving in and found to be in good condition, with any exceptions noted. I
understand that it is my responsibility to properly maintain the property and that I will be held liable for any damages occurring
during my tenancy, even if someone I have over as a guest causes the damages. I also understand that it is my responsibility to
give the landlord proper notice to vacate the premises and to sign the Post-Tenancy Inspection form when moving out of the
property; otherwise I will be held responsible for repayment of not only damages but for the extra month’s rent. Furthermore, I
understand that failure to do either may result in a recoupment from my future Temporary Assistance grant or recovery by any
legal means necessary for damages or unpaid rent, paid on my behalf to the landlord by OCDSS-ES under this agreement.
I declare under penalty of perjury, pursuant to Penal Law section 210.45, that the above information is true and correct, and I also understand that the
submission of this invoice to Onondaga County by any person who knows this invoice to contain false information, constitutes the additional crime of
Offering a False Instrument for Filing in the first degree (Penal Law Section 175.35).
This document is submitted to Onondaga County for the purpose of verification of the facts contained herein. I understand that I may be required to
repay any overpayment resulting from false or incorrect information and that I may be prosecuted for Larceny or attempted Larceny for knowingly
submitting any such false information on this document.
Notice to Landlord
Please read before signing
Please retain one copy of the pre-inspection form for your records and provide a signed copy to the client/tenant.
Please be aware that submitting a Pre-Tenancy Inspection form to OCDSS-ES in no way guarantees eligibility for, or
authorization of, a Landlord Tenant Security Agreement. In order to have a valid agreement the tenant must be in
receipt of Temporary Assistance and an OCDSS-ES validated Landlord Tenant Security Agreement must be on
file.
If the Pre-Tenancy Inspection Form and/or signed Landlord Tenant Security Agreement have been submitted, and the
client/tenant does not move into your property, you must notify the Onondaga County Department of Social Services-
Economic Security immediately at (315) 435-2700
I declare under penalty of perjury, pursuant to Penal Law section 210.45, that the above information is true and correct, and I also understand that the
submission of this invoice to Onondaga County by any person who knows this invoice to contain false information, constitutes the additional crime of
Offering a False Instrument for Filing in the first degree (Penal Law Section 175.35).
This document is submitted to Onondaga County for the purpose of verification of the facts contained herein. I understand that I may be required to
repay any overpayment resulting from false or incorrect information and that I may be prosecuted for Larceny or attempted Larceny for knowingly
submitting any such false information on this document.
INSPECTION DEFINITIONS
Walls
G
Freshly painted walls, new wallpaper, paneling free of defects. Few nail holes, marks or scratches; No washing, patching or repainting
needed.
F
Obvious marks; more than 5 small nail holes per wall, 0-5 holes less than 3 inches in diameter. Needs patching and touch-up.
P
Peeling paint, one or more holes larger than 3 inches in diameter; 6 or more holes less than 3 inches in diameter; graffiti; stains. Needs
patching and painting.
Carpets G
New or nearly new; free of rips or stains. Does not need cleaning.
F
Slight wear in traffic areas; moderate general soil, small stains. Needs routine cleaning.
P
Large and or multiple burns, tears, stains. Carpet destroyed, requires replacing.
Floors
G
New or nearly new vinyl or tile flooring; wood floor recently refinished or repainted; free of defects.
F
Slight wear, less than 5 small stains or tears, less than 5 damaged tiles; cleaning repair or touch-up needed.
P
Multiple tiles damaged; multiple stains; replacement, repainting, refinishing needed.
Ceilings G
Freshly painted; free of defects; all tiles in good condition; minor signs of wear, no repainting or repair needed.
F
Small marks, water spots, or holes; 1or 2 tiles need replacing; needs patching and touch up.
P
Major stains and/or holes; 3 or more tiles need replacing. Patching and/or repainting required.
Doors
G
Minor cosmetic damage to doors not affecting function or safety, appropriate locks operational.
F
Interior doors off hinges but otherwise undamaged; minor damage, scratches and/or knicks to door frame.
P
Exterior door unable to be secured; panels split or missing; excessive damage to door frame; locks destroyed.
Cleanliness
G
Free of trash and debris, appliances and bathroom fixtures clean, minor amount of cleaning upon move in required- “broom clean”
F
Moderate amount of cleaning required, light trash and debris, less than one hour of cleaning required per room.
P
Excessive trash and debris; in excess of one hour per room cleaning required throughout the unit.
IM-5357 Back Attachment
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Download Form IM5357 Attachment 5 "Pre-tenancy Inspection Form" - Onondaga County, New York

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