NYC 9/11 Public Portal Document
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DIVISION OF RE.AL ESTATE SERVICES
CREDIT INEORMATION AUTHORIZATION FORM
DRES Project No.; Premises Address
Applicant’s Name Borough Block Lot(s)
I understand that the City of New York (the City) will rely on the truthfulness of this disclosure statement (The
Statement) in determining my eligibility to lease the subject commercial property. The City may obtam a credit report(s)
on me in cormection with this application or any lease or occupancy relatmg thereto. If I ask, the City will tell me
whether it has obtamed a credit report and the name of the credit bureau.
Further, I hereby authorize the release of information to the Deputy Commissioner or designee of the New York City
Department of Citywide Administrative Services, Division of Real Estate Services pertaining to applicant’s payment of
taxes, fees, charges or other obligations to the United States government and the City and State of New York by the
appropriate agents of said governmental bodies.
The Statement is intended to be a written instrument as defined in Article 175 of the Penal Law, and I understand that
any false statement may be punishable as a Class E felony. If the Division of Real Estate Services discovers any matenal
misrepresentation, omission or false statement, the Division of Real Estate Services will not enter into a lease, license,
permit or other agreement for use and/or possession of real property.
1) Individual’s Name (print) 1) Individual’s Name (print)
2) Individual’s Signature 2) Individual’s Signature
Sworn to and subscribed before me Sworn to and subscribed before me
this day of 19. this day of 19
Notary Public or Commissioner of Deeds Notary Public or Commissioner of Deeds
Name of Entity (Print)
Name of OfiBccr/Title
Signature of Officer
Sworn to and subscribed before me
this day of 19___
Notary Public or Conunissioner of Deeds
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NYC-WTC_000170992
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