Online Form for contacting HRA before filing an eviction proceeding with the local housing court

You can use this form to contact the Human Resources Administration (HRA) if you are owed rent from a CityFHEPS or FHEPS tenant. HRA may be able to address the situation, and where appropriate, issue back rent to bring the client up to date and limit the possibility of future arrears.

This process is intended for landlords to use before they file an eviction proceeding with Housing Court. If you already started a court proceeding or are about to initiate one, we still might be able to help resolve the issue.

* Indicates required fields

Who is filling out the form?*

Landlord/Management Information

Please confirm: I have a tenant receiving CityFHEPS or FHEPS from the Human Resources Administration (HRA) that owes rent.*

Confirmed

Company Name*

Company Mailing Street Address*

Company Mailing Apartment/Suite

Company Mailing City*

Company Mailing State*

Company Mailing ZIP Code*

Company Email*
We will send you a confirmation email with the correspondence # to this email address once this form is submitted. You will also receive an email to this email address to send the supporting documents.

Company Phone Number*

Company Main Contact First Name*

Company Main Contact Last Name*

Tenant Household Information

Tenant First Name

Tenant Last Name

Tenant Street Address*

Tenant Apartment/Suite

Tenant State*

Tenant City*

Tenant ZIP Code * (zip code dependent on a valid Tenant City selection)

Tenant Email

Tenant Phone Number

Tenant DSS-HRA Case Number
The case number has ten characters. The first nine characters are numbers, and the final character is a letter. You can find the tenant's case number on the front of the rental subsidy checks.

Rental Assistance Type*

FHEPS CityFHEPS Unsure

Certification

Do not sign until you have read and understand the statement below.

I understand and agree to the following:

I must complete, submit, and sign this form to contact HRA regarding the rent arrears.
The information provided in this request is true and accurate.

Enter your name in lieu of signature*

Date Submitted*

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