HRA-121 (E) 06/30/2021
Date:
Tenant’s Name:
Lease ID # (if applicable):
Telephone Number:
Broker’s Request for Enhanced Fee Payment by Check
HRA will issue a check for a broker's fee for households that are exiting DHS and HRA shelters
as well as
certain other
households if
the tenant is otherwise eligible and the Broker meets all of the following criteria:
• The Broker has verified that the actual rental unit has a current Certificate of Occupancy in effect issued by the New
York City Department of Buildings, if applicable, or has confirmation that the rental unit’s use and/or type of occupancy
is in compliance with the local jurisdiction’s standards.
• No change has been made in the occupancy or use of the rental unit that is inconsistent with the last issued Certificate
of Occupancy or other equivalent document.
• No dangerous or hazardous violations are present on the premises.
• The Broker has a current broker's license in good standing.
• The Broker is not the owner, controlling person, or an affiliate of the owner of the actual rental unit.
• The lease or rental agreement is for one year or longer
I (we) _____________________________________________________________________________________, located at
Name of Broker
Address
Borough
State
Zip Code
request payment for services rendered in the form of a check in the amount of $ ____________________ on behalf of the
above-named tenant who will be the primary tenant of the premises located at:
Address
Apartment Number
Borough
State
Zip Code
This amount represents the entire broker’s fee. The tenant is not responsible for any monies in excess of the amount issued by
HRA, which is up to 15% of the annual rent. The enhanced broker’s fee will be offered for as long as funding remains
available. Visit http://www.nyc.gov/dsshousing to see if this enhanced fee is still available.
I (we) certify that I (we) have not requested any fees directly from the tenant, other than, if applicable, an incidental apartment
application fee required of all tenant applicants, and am (are) not aware of the landlord requesting any fees from the tenant
other than what is set forth in the lease/agreement.
I (we), as the Broker of the above-named premises, certify that this rental unit meets all of the criteria listed above.
I (we) agree to promptly refund to HRA the Broker's fee paid hereunder if the tenant fails to move into the above-described
premises or equivalent premises acceptable to the tenant.
Failure to provide true and accurate statements is punishable as a Class A Misdemeanor pursuant to Penal Law
§ 175.30 (offering a false instrument for filing to a public office or a public servant).
Broker’s Signature
Date
License Number
Telephone Number
If corporation, name of officer and corporate seal
