Get Caretaker For The Blind Form

Reset NYCHA 040. 567 Rev. 10/20/11 v1 COMMUNITY SERVICE Exemption Verification Primary Caretaker for the Blind or Disabled New YOrk city housing authority Name NYCHA Resident Giving Care Last P First Address Apt. A change in federal law requires adult residents to provide eight hours of Community Service or engage in eight hours of Economic Self-Sufficiency activity each month unless the resident qualifies for an exemption. A primary caretaker of a blind or disabled person who meets the requirements listed below qualifies for an exemption. The above named NYCHA resident states that he/she is one of your and return it to the NYCHA resident named at the top of this page. Print Name NYCHA Resident Receiving Care last first Account Telephone Borough Development I am the blind or disabled authorized NYCHA resident named in this box. I have already qualified for an Exemption from NYCHA Community Service due to blindness or disability because I either ubmitted to NYCHA management a completed COMMUNITY SERVICE Exemption Verification S Disability form signed by a medical doctor or optometrist or currently receive Supplemental Security Income SSI benefits and I already reported this to I NYCHA management or I currently receive Social Security Disability SSD payments and gave NYCHA proof by letter from the Social Security Administration. I hereby certify that the individual named at the top of this page takes care of me and is my primary caretaker. I understand that a primary caretaker must provide no less than 20 hours of care per week. Dated 20. I have already qualified for an Exemption from NYCHA Community Service due to blindness or disability because I either ubmitted to NYCHA management a completed COMMUNITY SERVICE Exemption Verification S Disability form signed by a medical doctor or optometrist or currently receive Supplemental Security Income SSI benefits and I already reported this to I NYCHA management or I currently receive Social Security Disability SSD payments and gave NYCHA proof by letter from the Social Security Administration. I hereby certify that the individual named at the top of this page takes care of me and is my primary caretaker. I understand that a primary caretaker must provide no less than 20 hours of care per week. Dated 20. Signature of Blind or Disabled NYCHA resident or guardian NOTE To avoid incidents of fraud representatives of the New York City Housing Authority will check NYCHA records and may contact you to verify the truth of the statements made above. The following information is about the blind or disabled NYCHA resident who is receiving the care. Note The caregiver and care receiver must both be authorized NYCHA residents but may live either in the same or in different apartments. Print Name NYCHA Resident Receiving Care last first Account Telephone Borough Development I am the blind or disabled authorized NYCHA resident named in this box. I have already qualified for an Exemption from NYCHA Community Service due to blindness or disability because I either ubmitted to NYCHA management a completed COMMUNITY SERVICE Exemption Verification S Disability form signed by a medical doctor or optometrist or currently receive Supplemental Security Income SSI benefits and I already reported this to I NYCHA management or I currently receive Social Security Disability SSD payments and gave NYCHA proof by letter from the Social Security Administration. I hereby certify that the individual named at the top of this page takes care of me and is my primary caretaker.