Part I. Tenant/Legal Occupant Statement
I, (insert name of tenant), state as follows:
(Choose the next part (A, B, or C) that most accurately describes your situation)
The person I have asserted has perpetrated domestic violence is my co-tenant, and I cannot safely give notice of my termination to my co-tenant. (YES/NO)
I reasonably fear that I cannot safely remain in my current apartment. I hereby terminate my lease effective (date at least thirty days after this notice is delivered).
_______________________ ___________
(signature of tenant) (date)
Acknowledgement
State of ______________________ | ) |
)ss.: | |
County of _____________________ | ) |
On the ______ day of __________ in the year _____, before me, the undersigned notary public, personally appeared _______________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
_________________________
Notary Public
Part II. Qualified Third Party Statement
I, (insert name of qualified third party), state as follows:
My employer name/address/phone number/e-mail address are as follows:
I am:
____ A law enforcement officer employed by the (insert law enforcement agency).
____ An employee of __________________________ court located in the state of _______________.
____ An attorney licensed to practice in (insert name of state(s)).
____ A physician licensed to practice in (insert name of state(s)).
____ A psychiatrist licensed to practice in (insert name of state(s)).
____ A psychologist licensed to practice in (insert name of state(s)).
____ A social worker licensed to practice in (insert name of state(s)).
____ A nurse licensed to practice in (insert name of state(s)).
____ A therapist or clinical professional counselor licensed to practice in (insert name of state(s));
____ Employed by a government or non-profit agency or service that advises persons regarding domestic violence or refers them to persons or agencies for services or advice.
____ A member of the clergy of a church or religious society or denomination.
____ Other (describe):_________________________________________________
The person who signed the Tenant/Legal Occupant Statement above has stated to me that he/she/they, or a member of his/her/their household, has been subject to domestic violence.
This person further stated to me the incident(s) occurred on or about the date(s) stated above.
I understand that the person who signed the Tenant/Legal Occupant Statement may use this document as a basis for terminating a lease with the person's lessor.
__________________________________________
(name of qualified third party)
__________________________________________
(signature of qualified third party)
______________
(date)
Acknowledgement
State of ______________________ | ) |
)ss.: | |
County of _____________________ | ) |
On the _______ day of ___________ in the year _____, before me, the undersigned notary public, personally appeared _________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
____________________________________________
Notary Public
Part III. Statement of Interpretation/Translation
I am bilingual in English and ____________ and have translated or interpreted this document to the best of my ability for the signer above.
_________________________________________
(name of interpreter/translator)
_________________________________________
(signature of interpreter/translator)
___________________
(date)
Acknowledgement
State of ______________________ | ) |
)ss.: | |
County of _____________________ | ) |
On the _______ day of ___________ in the year _____, before me, the undersigned notary public, personally appeared ________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
____________________________________________
Notary Public
N.Y. Real Prop. Law § 227-C