COVID-19 Application For Suspension Of Debt Collection Activity

This application is for persons or businesses that owe (non-medical and non-student*) debts to the State of New York that have been referred to the Office of the Attorney General for collection and litigation. Any such person or business, or their dependents, that have been financially impacted by COVID-19, or the international, national, and state responses designed to prevent its spread, may complete and submit this application to be considered for certain forms of relief, including relief from collection activity, interest accrual, and the assessment of collection fees.

* NO APPLICATION IS NECESSARY FOR MEDICAL AND STUDENT DEBT - On March 17, 2020, New York Attorney General Letitia James initially announced that her office would temporarily halt the collection of medical and student debt referred to the Office of the Attorney General for collection, for at least a 30-day period, in response to growing financial impairments resulting from the spread of COVID-19. On April 17, 2020 and again on May 18, 2020, Attorney General James renewed the order for additional 30-day periods, which is now in effect until June 16, 2020.

Due to the financial impact of COVID-19 response, I request that the Office of the Attorney General (OAG) provide debt relief for a debt that has been referred to the OAG by a State Agency. I understand that, at the sole discretion of the OAG, the potential debt relief available for those impacted by the response to COVID-19 includes the temporary waiver of pre-judgment interest, including State Finance Law interest that may apply 35 days after a demand for payment is sent, the temporary waiver of collection fees, including the State Finance Law collection fee that may apply 95 days after a demand for payment is sent, the temporary tolling of time periods counting toward the 35 and 95 day time periods referenced above, the temporary waiver of post-judgment interest that accrues under the C.P.L.R on filed judgments, the decertification of debts from the Statewide Offset Program (SWOP) that intercepts tax refunds and contract payments to debtors, the temporary cessation of judgment enforcement for accounts in judgment, the temporary postponement of payments due, and the modification of payment agreements previously entered into with the Office of the Attorney General.

Application Information

The applicant is the party that owes a debt to a New York State agency that has been referred to the Office of the Attorney General by a State agency and requests debt relief for the debt.

First Name *

Last Name *

Date of Birth *

Month

Day

Year

E-mail Address *

Phone Number *

(ex:999-999-9999 or 999-999-9999 x9999)

Cell Phone Number

(ex:999-999-9999)

Street Address (Include Apt. #, if applicable) *

City/Town

State *

Zip *

(ex:12345 or 12345-1234)

County *

Describe Your Relationship to the Party Impacted by COVID-19

Examples include, but are not limited to, yourself or the spouse, domestic partner, or legal dependent of a person or entity affected by COVID-19. Attach any available documentation as further described in Section 9 below.

Describe

Information Related to Employment or Business Circumstances

Applicants should complete this section with information related to their employment or business circumstances. Spouses, domestic partners and legal dependents of persons that have lost income due to the COVID-19 response should complete this section with information relating to the employment or business circumstances of their spouse, domestic partner or party claiming them as a legal dependent. Attach any available documentation as further described in below.

Name of Employer or other impacted business

Address of Employer or other impacted business

Describe the Impact of COVID-19 on Your Employment or Business

Examples include, but are not limited to, forced closure of your business, being laid off, or describing how your employer or the business you are associated with has been impacted by COVID-19. Attach additional pages if needed.

Describe

Describe How You Have Been Financially Impacted by COVID-19

Applicants must demonstrate a reduction of income or other material financial impact. Attach additional pages if needed. Attach any available documentation as further described in Section 9 below

Describe

Additional Information

Please provide any other additional information that may be of assistance in reviewing your application for Debt Relief.

Additional Information

Attach Your Documents

Please provide documentation relevant to the above sections. In addition, any available documentation concerning status as third party vendor, contractor, other impacted party, spouse, domestic partner or legal dependent should also be provided. Furthermore, any available documentation demonstrating a reduction of income or other material financial impact should be provided.

File 1

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp tif txt pdf doc docx xls xlsx.

File 2

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp tif txt pdf doc docx xls xlsx.

File 3

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png bmp tif txt pdf doc docx xls xlsx.

I certify that, to the best of my knowledge and belief, the facts set forth in the foregoing application are true, correct and complete. I understand that this information is to be used to determine eligibility for debt relief. I understand that the information provided may be verified by the Office of the Attorney General. If asked by an authorized official, I agree to give further proof of the information that I have provided on this form.

Signature

Date

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