RA-23.5 (10/20)
Notice To Owner Of Family Members Residing With The Named Tenant In The Apartment
Who May Be Entitled To Succession Rights/Protection From Eviction
Gertz Plaza
92-31 Union Hall St.
Jamaica, NY 11433
State of New York
Division of Housing and Community Renewal
Oce of Rent Administration
Web Site: www.hcr.ny.gov
Please check appropriate box below:
Notice Requested by Owner
Notice Submitted by Tenant
Mailing Address of Tenant: Mailing Address of Owner/Agent:
Tenant’s Name Owner’s/Agent’s Name
Number/Street Apt. No. Number/Street
City, State, Zip Code City, State, Zip Code
Subject Building (if dierent from tenant’s mailing address):
Number and Street Apt. No. City, State, Zip Code
For the purpose of determining the right of a family member to a renewal lease or protection from eviction pursuant to rent
regulations, as described on the reverse side of this form, the information below may be requested by owners, or provided by
tenants, as follows:
(1) by owners of rent stabilized apartments, at any time, but no more often than once in twelve months;
(2) by owners of rent controlled apartments, at any time;
(3) by tenants of rent stabilized and rent controlled apartments, at any time.
The following information may be requested by owners or provided by tenants:
(1) the name of any person(s) other than the named tenant(s) who are residing in the apartment;
(2) whether such person is a “family member”* of the tenant and if such person is, or upon the passage of the applicable
period of required minimum residency, may become, a person entitled to be named as a tenant on a renewal lease
(for rent stabilized apartments), or protection from eviction (for rent controlled apartments), and the date such person
commenced primary residence with the tenant;
(3) whether such person is a “senior citizen” or “disabled person.”*
The tenant must provide the owner with the name of any person who has the right to be named as a tenant on a renewal
lease, whether or not the owner requests the information.
A statement of general rights and obligations of tenants and owners, including renewal lease rights of stabilized tenants, can
be found in the New York City Lease Rider For Rent Stabilized Tenants, Emergency Tenant Protection Act (ETPA)
Standard Lease Addenda or in DHCR Fact Sheets.
Instructions For Tenant
When a tenant provides a completed copy of this form to the owner, the tenant should obtain and keep proof thereof,
including a completed copy of the form. The owner should also keep a completed copy of the form. A family member
seeking to establish the right to a renewal lease or to protection from eviction upon the vacancy of the tenant may point to
the submission of this form to show that this information was given to the owner. This may provide some evidence of the
family member’s succession rights; however, an owner may later challenge the statements made in this form. Moreover, an
owner may use the information in this form if any later statements are inconsistent with the statements made in this form.
Statement of Tenant
Names of persons other than tenant(s)
residing in the apartment.
Date of commencement
of primary residence in
the apartment by such
persons.
Family relationship,* if any (If relationship
is not listed under 3 (a)(i) on reverse side, but
meets the requirements of 3 (a) (ii), indicate
“other family member” or “OFM”).
Check box if such
persons are senior
citizens and/or
disabled persons.
Senior
Citizen*
Disabled
Person*
1.
2.
3.
4.
For additional persons, check box and attach separate sheet.
Signature(s) of Tenant(s) Date
* See denitions on reverse side of this form.
RA-23.5 (10/20) - 2 -
Family Member’s Renewal Lease and Eviction Protection Rights
1. For rent-stabilized and rent-controlled apartments throughout New York State, except where occupancy is restricted by
income limitations pursuant to federal, state or local law, regulations or other governmental agency requirements, where
a tenant permanently vacates an apartment, any “family member” of the tenant as dened below shall have the right
to a renewal lease (rent stabilization), or to protection from eviction (rent control), provided that such family member
has resided with the tenant as a primary resident in the apartment for 2 years (1 year for “senior citizens” or “disabled
persons”) immediately prior to the permanent vacating of the apartment by the tenant, or from the inception of the
tenancy or commencement of the relationship, if for less than such periods.
2. For all housing accommodations, the minimum residency requirements will not be deemed to be interrupted by any
period during which a family member temporarily relocates from the housing accommodation because he or she:
(i) is engaged in active military duty;
(ii) is enrolled as a full-time student;
(iii) is not in residence at the housing accommodation pursuant to a court order not involving any term or provision of
the lease, and not involving any grounds specied in the Real Property Actions and Proceedings Law;
(iv) is engaged in employment requiring temporary relocation from the housing accommodation;
(v) is hospitalized for medical treatment; or
(vi) has other reasonable grounds that shall be determined by the DHCR upon application by the family member.
3. Denitions:
a. “Family Member” is dened as:
(i) A spouse, son, daughter, stepson, stepdaughter, father, mother, stepfather, stepmother, brother, sister, grandfather,
grandmother, grandson, granddaughter, father-in-law, mother-in-law, son-in-law or daughter-in-law of the tenant (or
permanent tenant for New York City rent stabilized hotels).
(ii) In addition to such “traditional” family members, for the purpose of renewal lease and eviction protection rights,
a family member also includes those persons (nontraditional family members) who have resided with the tenant,
as set forth in item 1 above, in a familial relationship based upon emotional and nancial commitment and
interdependence with the tenant or permanent tenant.
Several factors are considered in determining whether such commitment and interdependence existed between the
tenant and family member, and no single factor is solely determinative. These factors are:
— there is longevity to the relationship (this consideration is separate from the required minimum residency
periods discussed above, and may include the length of the relationship between the family member and the
tenant prior to occupancy of the housing accommodation at issue);
— they have shared or relied upon each other for payment of household or family expenses and/or other common
necessities of life; joint ownership of personal and real property, credit cards and loan obligations;
— they have intermingled their nances (for example, joint bank accounts or sharing a household budget for
purposes of receiving government benets);
— they have attended family functions together, or held themselves out as family members to other family
members or society in general;
— they have formalized legal obligations with each other (for example, executing wills naming each other as
executor and/or beneciary, or serving as representative payees for purposes of public benets; granting each
other a power of attorney and/or conferring upon each other authority to make health care decisions each for the
other; entering into a personal relationship contract);
— they relied upon each other for daily family services (for example, assistance during illness);
— engaging in any other pattern of behavior, agreement, or other action which evidences the intention of creating a
long-term, emotionally-committed relationship.
Sexual relationships between tenants and such family members will not be considered as a factor.
b. A “Senior Citizen” is dened as :
A person who is sixty-two years of age or older.
c. A “Disabled Person” is dened as:
A person who has an impairment which results from anatomical, physiological or psychological conditions, other than
addiction to alcohol, gambling, or any controlled substance, which are demonstrable by medically acceptable clinical
and laboratory diagnostic techniques, and which are expected to be permanent and which substantially limit one or
more of such person’s major life activities.
