(d) The following sample forms shall satisfy the notice and
verification requirements but are not required. These sample forms shall
be posted to the New York state unified court system's website, and
shall be made available in the state's family, civil, housing, criminal,
and supreme courts:
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)
(A) I have been subject to domestic violence. Date(s) of recent
incident(s) happened on or about:
(B) A member of my household has been subject to domestic violence.
Date(s) of recent incident(s) happened on or about:
(C) Both I and at least one member of my household have been subject to
domestic violence. Date(s) of recent incident(s) happened on or about:
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 _____________________)