Form HUD-50066 Certification of Domestic Violence, Dating Violence, or

Public reporting burden for this collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. Information provided is to be used by PHAs and Section 8 owners or managers to request a tenant to certify that the individual is a victim of domestic violence, dating violence or stalking. The information is subject to the confidentiality requirements of the HUD Reform Legislation. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number.

Purpose of Form: The Violence Against Women and Justice Department Reauthorization Act of 2005 protects qualified tenants and family members of tenants who are victims of domestic violence, dating violence, or stalking from being evicted or terminated from housing assistance based on acts of such violence against them.

Use of Form: Within 14 business days of receiving the written request for this certification by the PHA, owner, or manager, an individual seeking protection from eviction or termination of assistance as a result of domestic violence may complete and submit this certification form: or in lieu of the certification form, provide information related to his/her domestic violence incident.. The certification or alternate document or verbal statement must be provided to the PHA, owner, or manager. If the individual has not provided the requested certification or the information that may be provided in lieu of the certification by the 14^th business day or any extension of the date provided by the PHA, manager or owner, none of the protections afforded to victims of domestic violence, who participate in the Section 8 or public housing programs will apply. Distribution or issuance of this form by PHAs, owners or managers does not serve as a written request for certification

Note that an individual may provide, in lieu of this certification (or in addition to it):

(1) A Federal, State, tribal, territorial, or local police or court record; or

(2) Documentation signed by an employee, agent or volunteer of a victim service provider, an attorney or a medical professional, from whom the individual has sought assistance in addressing domestic violence, dating violence or stalking, or the effects of abuse, in which the professional attest under penalty of perjury (28 U.S.C. 1746) to the professional’s belief that the incident or incidents in question are bona fide incidents of abuse, and the victim of domestic violence, dating violence, or stalking has signed or attested to the documentation.

(3) Victim’s written or verbal statement or other corroborating evidence.

____________________________________________________________

TO BE COMPLETED BY THE INDIVIDUAL OF DOMESTIC VIOLENCE:

Date Written Request Received By Individual:___________________

Name of the individual of domestic violence or dating violence or stalking: _____________________________________________________________________________

Name(s) of family members listed on the lease (if not individual): _____________________________________________________________________________

Name of the abuser: ___________________________________________

Relation to individual: _____________________________________________________________

Date the incident of domestic violence occurred:_______________________

Time: _______________________________________________________

Location of Incident: ___________________________________________

Name of Individual:

Description of Incident:

I hereby certify that the information that I have provided is true and correct and I believe that, based on the information I have provided, that I am a victim of domestic violence, dating violence or stalking and that the incident(s) in question are bona fide incidents of such actual or threatened abuse. I acknowledge that submission of false information relating to program eligibility is a basis for termination of assistance or eviction.

Signature Executed on (Date)

All information provided to a PHA, owner or manager relating to the incident(s) of domestic violence, including the fact that an individual is a victim of domestic violence shall be retained in confidence by an owner and shall neither be entered into any shared database nor provided to any related entity, except to the extent that such disclosure is (i) requested or consented to by the individual in writing; (ii) required for use in an eviction proceeding or termination of assistance; or (iii) otherwise required by applicable law.

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form HUD-50066

(11/2006)