COVID-19 Application For Suspension Of Debt Collection Activity Debt Relief Request Form

Please fill out this form if:

You are financially impacted by the COVID-19 pandemic; AND
You want temporary debt relief for debts that have been referred to the OAG for collection

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 *

E-mail Address *

Phone Number *

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

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

City/Town

State *

Zip *

(ex:12345 or 12345-1234)

Employer Information

Your Employer's Name

Employer's Street Address

City/Town

State

Zip

Financial Impact

How has the pandemic affected you financially? *

I lost my job

A member of my household lost their job

My household income has been cut due to reduced work hours

Remote schooling/lack of childcare or adult-care prevents me, or a member of my household, from working

Other (please explain below)

If you selected "Other", please explain:

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

Leave this field blank