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.