Certification of Correction of Violation(s)

Certification of Correction of Violation(s)
(Fill in entire form and sign below)

State of New York)
County of _______) ss:

I, ___________________, swear or affirm under penalty of perjury
as follows:

1. That I am: (check applicable box)

[  ] the Owner of the property
[  ] the Registered Agent of the property
[  ] an Officer of the Corporation owning the property
[  ] otherwise registered as responsible for the property

2. If this is a multiple dwelling, or if I do not live in the
City of New York and I am the owner of a one or two-family house,
that I have duly registered with the Office of Rent and Housing
Maintenance, Division of Code Enforcement for the subject
property.

3. That I have examined the area(s) containing the violation(s)
on the reverse side of this form, and, to my knowledge, such
violation(s) whose number(s) I have circled were corrected on the
date(s) I have indicated.

4. That the following are the name(s) and address(es) of my
agent(s) or employee(s) who performed the work to correct the
violation(s) that I have certified as corrected. (Identify this
information by item number below. Use photostats of this form, if
necessary).

Item    |   Name of agent(s)         |   Addresses of Agent(s)
Number  |   or Employees             |   or Employees
        |   who performed the work   |   who performed the work
========|============================|=========================
        |                            |
        |                            |
        |                            |
========|============================|=========================


______________________________________________
Signature

Sworn to me before this ____ day of __________

______________________________________________
Notary Public

The making of a false certifcation is a crime punishable by a
fine and/or imprisonment.