(b) Such notice shall state that the tenant or a member of the tenant's household has experienced domestic violence and reasonably believes the tenant, or the member of the tenant's household, is unable to safely remain in the leased premises as a result of the domestic violence.
(c) Within twenty-five days of such notice, the tenant shall provide documentation demonstrating that the tenant or a member of the tenant's household has been a victim of domestic violence as described in subdivision one of this section. This documentation may include any one or more of the following:
(i) A temporary or final order of protection issued by a court of competent jurisdiction;
(ii) A record, complaint, or report from a federal, state, or local law enforcement agency of an act of domestic violence as described in section four hundred fifty-nine-a of the social services law or a family offense as described in section eight hundred twelve of the family court act, or certifying that the tenant or a member of the tenant's household has been subjected to domestic violence;
(iii) A record from a health care provider for treatment related to domestic violence as described in section four hundred fifty-nine-a of the social services law or a family offense as described in section eight hundred twelve of the family court act;
(iv) A written verification from any other qualified third party to whom the tenant, or a member of the tenant's household reported the domestic violence.
(A) "Qualified third party" shall include: any law enforcement officer; employee of a court of the state; attorney, physician, psychiatrist, psychologist, social worker, registered nurse, therapist, or clinical professional counselor licensed to practice in any state; person employed by a government or non-profit agency or service that advises or provides services to persons regarding domestic violence; or any member of the clergy of a church or religious society or denomination.
(B) Written verification as described herein shall be satisfied by any sworn or notarized statement including the required information.
(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 _____________________) )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 3. Treatment of rent. (a) The tenant terminating the lease shall pay rent, pro-rata, up to the lease termination date pursuant to this section.
(b) The tenant terminating the lease shall be entitled to a refund for any prepaid rent or other payments covering the period after the effective date of the lease termination, as long as the tenant has vacated the premises. Such refund shall be provided within ten days of delivery of the written notice as outlined in subdivision two of this section.
(c) A tenant who meets the requirements in subdivision one of this section and submits proper notice pursuant to subdivision two of this section shall have a defense in any action brought by a landlord against such tenant to recover rent and/or damages for breach of lease and shall not be liable for any rent after the effective termination date.
(d) The lessor or owner may withhold a security deposit in part or in full to the extent allowed by the lease or statute, except for the early termination granted by this section, and shall not withhold any part of the security deposit due to the tenant's exercise of rights under this section.
(e) Nothing in this section shall be construed to be a defense against an action for rent for a period of time before the tenant vacated the premises and gave notice as required in subdivision two of this section. 4. Co-tenants and other occupants. Upon termination:
(a) If the terminating tenant is the sole leaseholder, the premises shall be delivered to the lessor or owner:
(i) free of all tenants and occupants, provided that the terminating tenant shall not be responsible for ensuring that the abusive household member is not present; and
(ii) in accordance with the terms of the lease relating to delivery of the premises at the termination of the lease.
(b) If there are tenants on the lease other than the terminating tenant:
(i) the landlord shall not, except upon consent of such additional tenants, terminate or sever the co-tenancy. The landlord must provide the remaining tenant at least thirty days from the termination date to decide whether to consent to a termination or severance.
(ii) The remaining co-tenant or co-tenants hold the right to add an additional occupant as defined by paragraph (b) of subdivision one of section two hundred thirty-five-f of this article. 5. Confidentiality provisions. (a) Unless the terminating tenant provides written authorization for the release of information or unless required by law, court order, or statute, the information shall not be released. Information that shall be kept confidential shall include information obtained during the process of the tenant terminating his or her lease in accordance with this section, such as: (i) the nature of the termination, (ii) the status of the tenant or member of the tenant's household as a victim of domestic violence, and (iii) any information contained in documentation provided to demonstrate status as a victim of domestic violence.
(b) Pursuant to this section, the landlord shall not divulge, describe, or characterize the termination of the rental agreement as an early termination by a current lessor to a prospective lessor or any third party. 6. Violations. (a) Landlords who knowingly, or intentionally violate any part of this section may be liable for liquidated damages, not to exceed one thousand dollars, actual damages, costs and attorneys' fees.
(b) Any agreement by a lessee or tenant of premises occupied for dwelling purposes waiving or modifying his or her rights as set forth in this section shall be void as contrary to public policy.