Information Collection

Certification of Domestic Violence, Dating Violence, or Stalking

IC 46037 under ICR 200611-2577-002 · OMB 2577-0249.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2577-0249 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HUD-XXX Certification of Domestic Violence, Dating Violence, or Stalking	Form and Instruction
HUD-XXX Certification of Domestic Violence, Dating Violence, or VAWA form.doc	Form and Instruction

IC Title:

Certification of Domestic Violence, Dating Violence, or Stalking

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HUD-XXX	Certification of Domestic Violence, Dating Violence, or Stalking	VAWA form.doc		No		Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	4,800	4,800

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.