Paperwork Reduction Act Submission
Please read the instruction before completing this form. For additional forms or assistance in completing this forms, contact your agency’s Paperwork Reduction Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 Seventeenth St. NW, Washington, DC 20503.
1. Agency/Subagency Originating Request: U.S. Department of Housing and Urban Development Office of Public and Indian Housing (PIH)
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2. OMB Control Number: a. 2577-0249
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b. None
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3. Type of information collection: (check one)
collection for which approval has expired
for which approval has expired
For b-f, note item A2 of Supporting Statement instructions. |
4. Type of review requested: (check one)
5. Small entities: Will this information collection have a significant economic impact on a substantial number of small entities? Yes No 6. Requested expiration date: a. Three years form approval date b. Other (specify)
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7. Title:
Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking
8. Agency form number(s): (if applicable)
HUD-50066
9. Keywords:
Housing, Public Housing Agencies (PHAs), Section 8 Vouchers, domestic violence, dating violence, sexual assault, or stalking
10. Abstract:
The Violence Against Women Reauthorization Act of 2013 (“VAWA”) protects qualified tenants, participants, applicants, and affiliated individuals, who are victims of domestic violence, dating violence, sexual assault or stalking. This is an optional form. A PHA, owner, or management agent presented with a claim for continued or initial tenancy or assistance based on status as a victim of domestic violence, dating violence, sexual assault or stalking has the option to request that the victim document or provide written evidence to demonstrate that the violence occurred.
11. Affected public: (mark primary with “P” and all others that apply with “X”) a. X Individuals or households e. Farms b. Business or other for-profit f. Federal Government c. Not-for-profit institutions g. P State, Local or Tribal Government |
12. Obligation to respond: (mark primary with “P” and all others that apply with “X”) a. Voluntary b. X Required to obtain or retain benefils c. P Mandatory |
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13. Annual reporting and recordkeeping hour burden: a. Number of respondents 200 b. Total annual responses 200 Percentage of these responses collected electronically 0% c. Total annual hours requested 200 d. Current OMB inventory 200 e. Difference (+,-) 0 f. Explanation of difference: 1. Program change: 2. Adjustment: |
14. Annual reporting and recordkeeping cost burden: (in thousands of dollars) a. Total annualized capital/startup costs $0.00 b. Total annual costs (O&M) $ 0.00 c. Total annualized cost requested $ 0.00 d. Total annual cost requested $ 0.00 e. Current OMB inventory $ 0.00 f. Explanation of difference: 1. Program change: 0 2. Adjustment: 0 |
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15. Purpose of Information collection: (mark primary with “P” and all others that apply with “X”) a. X Application for benefits e. Program planning or management b. Program evaluation f. Research c. General purpose statistics g. P Requlatory or compliance d. Audit |
16. Frequency of recordkeeping or reporting: (check all that apply) a. Recordkeeping b. Third party disclosure b. Reporting: 1. On occasion 2. Weekly 3. Monthly 4. Quarterly 5. Semi-annually 6. Annually 7. Biennually 8. Other (describe)
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17. Statistical methods: Does this information collection employ statistical methods? Yes No
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18. Agency contact: (person who can best answer questions regarding the content of this submission) Name: Ryan Jones Phone: (202) 402-2677
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19. Certification for Paperwork Reduction Act Submissions
On behalf of the U.S. Department of Housing and Urban Development, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9.
Note: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320/8(b)(3). appear at the end of the instructions. The certification is to be made with reference to those regulatory provisions as set forth in the instructions.
The following is a summary of the topics, regarding the proposed collections of information, that the certification covers:
It is necessary for the proper performance of agency functions;
It avoids unnecessary duplication;
It reduces burden on small entities;
It uses plain, coherent, and unambiguous terminology that is understandable to respondents;
Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
It indicates the retention periods for recordkeeping requirements;
It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
Why the information is being collected;
Use of the information;
burden estimate;
Nature of response (voluntary, required for a benefit, or mandatory);
Nature and extent of confidentiality; and
Need to display currently valid OMB control number;
It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to collected (see note in item 19 of the instructions);
It uses effective and efficient statistical survey methodology; and
It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in item 18 of the Supporting Statement.
Signature of Program Official:
X Milan Ozdinec, Deputy Assistant Secretary, Office of Public and Voucher Programs, PE
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Date: |
Supporting Statement for Paperwork Reduction Act Submissions
A. Justification
1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.
The Violence Against Women Reauthorization Act of 2013 (VAWA 2013), Public Law 113-4, 127 Stat. 54, reauthorized and amended the Violence Against Women Act of 1994, as previously amended (title IV, sec. 40001-40703 of Public Law 103-322, 42 U.S.C. 13925 et seq.). In order to fully implement the provisions of VAWA that afford protections to victims of domestic violence, dating violence, sexual assault, or stalking, the Department must revise the HUD-approved certification form for victims to submit and sign certifying that the individual is a victim of domestic violence, dating violence, sexual assault, or stalking and that the incident in question is bona fide. See Title VI of VAWA 2013, Section 41411.
2. Indicate how, by whom and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
PHAs, owners, and managers will use the information in order to evaluate whether an individual is entitled to protection under VAWA.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
This is a limited collection and will not affect a large number of individuals therefore; it would not be cost effective to automate the collection.
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
Similar certification forms related to this purpose are not already available.
5. If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I) describe any methods used to minimize burden.
This collection does not impact small businesses or other entities.
6. Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
The consequences to Federal program or policy activities if the collection is not conducted are that HUD would be in violation of the law and could be sued; and the information may be construed to limit the authority of the PHA to evict any tenant or lawful occupant that commits violations of the lease.
Explain any special circumstances that would cause an information collection to be conducted in a manner:
requiring respondents to report information to the agency more than quarterly;
requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;
requiring respondents to submit more than an original and two copies of any document;
requiring respondents to retain records other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
in connection with a statistical survey, that is not designed to produce valid and reliable results than can be generalized to the universe of study;
requiring the use of a statistical data classification that has not been reviewed and approved by OMB;
that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
Respondents must provide the certification form (or alternate documentation as described on the certification form) by 14 days (or any extension of that date provided by the PHA, owner or management agent) after receiving written request for the certification by the PHA, owner, or management agent. Without this certification (or alternate documentation as described on the certification form), a PHA, owner, or management agent may evict, deny, or terminate assistance to a domestic violence victim, and cannot be assured s/he will receive VAWA protections.
8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.
Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping disclosure, or reporting format (if any) and the data elements to be recorded, disclosed, or reported.
Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection of information activity is the same as in prior periods. There may be circumstances that preclude consultation in a specific situation. These circumstances should be explained.
HUD published a Notice of Proposed Information Collection for public comments in the Federal Register, Volume 78, Page 78375 on December 26, 2013. The public was given until February 24, 2014, to submit comments on the proposed information collection. HUD received comments from Columbia Housing Authority and National Network to End Domestic Violence. Comments are attached.
9. Explain any decision to provide any payment or gift to respondents, other than reenumeration of contractors or grantees.
No payment or gift will be made to respondents.
10. Describe any assurance of confidentiality provided to respondents and the basis for assurance in statute, regulation or agency policy.
The information provided by the victim of domestic violence, dating violence, sexual assault or stalking pursuant to the certification form will be retained in confidence and not entered into any shared database nor provided to any related entity except when the disclosure is: requested or consented to by the individual in writing, requiring for use in eviction proceedings, or otherwise required by law.
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
VAWA 2013 provides that, at the request of a PHA, owner or manager, that an individual may certify, via a HUD-approved certification form that the incident or incidences of abuse are bona fide. VAWA 2013 requires that the form include the name of the perpetrator of the violence only if the name of the perpetrator is safe to provide, and is known to the victim. VAWA also establishes a 14-day deadline (plus any extensions granted by the PHA, owner or management agent) from the date of the request for such certification, to return the form. The Department therefore considers the form and its contents necessary in order for victims of abuse to receive the protections of VAWA. Recognizing that domestic violence is a sensitive topic and that victims of abuse may be reluctant to fill out the certification, the Department has tried to develop a form that clearly and concisely explains the purpose of the form and what information is required. To that end, the form itself has a section that explains its purpose and another section that explains how to use the form, the timeline for submitting the form to the PHA, owner and management agent, and that the protections of VAWA may not apply if the form is not submitted in a timely manner. The form also informs the individual of alternate documentation that may satisfy the certification requirement as well as provides a confidentiality statement.
12. Provide estimates of the hour burden of the collection of information. The statement should:
indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally estimates should not include burden hours for customary and usual business practices;
if this request covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I; and
provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead this cost should be included in Item 13.
Total Burden Hour Estimates |
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Type of Submission |
Number of Respondents |
Frequency of Requirement |
X |
Est. Avg. Time for Requirement (Hours) |
Total Hours |
Cost per Hour |
Total Cost |
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HUD-VAWA |
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1 |
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1 |
200 |
$24 |
$4800 |
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13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information (do not include the cost of any hour burden shown in Items 12 and 14).
The cost estimate should be split into two components: (a) a total capital and start-up cost component (annualized over its expected useful life); and (b) a total operation and maintenance purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s) and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities;
If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10) utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.
generally, estimates should not include purchases of equipment or services, or portions thereof made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.
There are no addiditonal costs to PHAs.
14. Provide estimates of annualized cost to the Federal government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.
We do not estimate that there will be any additional costs to the Federal government for this information collection.
15. Explain the reasons for any program changes or adjustments reported in Items 13 and 14 of the OMB Form 83-I.
HUD does not anticipate a direct cost to the Federal government as a result of the provision and collection of form HUD-50066 by PHAs to victims of domestic violence, dating violence, sexual assault, or stalking. HUD’s participation is not required for a PHA to extend VAWA 2013 protections to victims. HUD did make changes to form HUD-50066 to reflect the requirements of VAWA 2013. These changes include: Adding sexual assault to the list of domestic violence, dating violence, or stalking; That the victim of domestic violence, dating violence, sexual assault, or stalking is required to provide the name of the perpetrator only if the name of the perpetrator is safe to provide and is known to the victim; and Expanding upon the acceptable forms of documentation. The changes to HUD-50066 are not anticipated to create additional costs to PHAs as they are already required to provide form HUD-50066 and adhere to the requirements of VAWA 2013.
16. For collection of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.
There will be no publication of information collections.
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
HUD is not seeking approval to avoid displaying the OMB expiration date.
18. Explain each exception to the certification statement identified in item 19.
There are no exceptions to the certification statement identified in item 19 of the OMB 83-i.
B. Collections of Information Employing Statistical Methods
This collection of information will not be used for statistical purposes.
OMB 83-I 10/95
| File Type | application/msword |
| File Title | Paperwork Reduction Act Submission |
| Author | Lillian L. Deitzer |
| Last Modified By | Arlette Annette Mussington |
| File Modified | 2014-02-25 |
| File Created | 2014-01-13 |