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.

(ex:999-999-9999 or 999-999-9999 x9999)
(ex:12345 or 12345-1234)
Employer Information
Financial Impact

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.