New York Primary Tenant's Statement Regarding Occupancy of Secondary Tenant
Form W-147Q LLF
Primary Tenant's Statement Regarding
Occupancy of Secondary Tenant
Primary Tena nt's Name:
Secondary Tenant's Name:
Case Number (if any):
Borough : Zip Code:
Borough: Zip Code:
I, , do hereby declare tha t I am the primary tenant of
apartment located at
I do also declare that also lives on these premises.
(name of secondary tenant)
I charge $ per month rent for providing shelter (heat/utilities). Attached is a copy
of my lease or other documentatio n demonstrating that I am a legal tenant of this apartmen t.
Rent payment method (check the applicable boxes):
Rent is paid direct ly to the landlord.
Rent is paid directly to me.
I share meals with the se condary tenant named above:
I swear under penalty of perjury that the information I have given on this form is correct and complete to the best
of my knowledge.
Signature of Primary Tenant Telephone
New York Primary Tenant's Statement Regarding Occupancy of Secondary Tenant PDF
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