The tenants owe rent for the following months (list the amount owed for each month):
$_________ for month of ____________, 20___ $_________ for month of ____________, 20___
$_________ for month of ____________, 20___ $_________ for month of ____________, 20___
$_________ for month of ____________, 20___ $_________ for month of ____________, 20___
$_________ for month of ____________, 20___ $_________ for month of ____________, 20___
$_________ for month of ____________, 20___ $_________ for month of ____________, 20___
The total amount of rent owed is: $_______________.
The tenants were served with a written demand to pay past due rent, including the good cause
eviction law notice, instructing them to pay the rent owed or to move out within 14 days. A copy of the
form and proof (affidavit or affirmation) of service are attached.
If the property is located in the city of Albany, Newburgh, or Syracuse, the premises has been
registered with the city as a condition of legal rental as required by RPAPL 741 (6), (7), or (8).
A copy of Notice to Tenant of Applicability or Inapplicability of the New York State Good Cause
Eviction Law is attached.
The tenants continue to occupy the premises without permission after failing to pay the rent.
ADA Accommodations Spoken or Sign Language Interpreters 1-800-COURT-NY
ada@nycourts.gov interpreter@nycourts.gov (268-7869)
UCS-LTN2 (03/2025) Page 2 of 8 Index Number: __________________