Form 5382 Certification of Domestic Violence Dating Violence Sexua

CERTIFICATION OF DOMESTIC VIOLENCE, DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING

U.S. Department of Housing and Urban Development OMB Approval No. 2577-0286 Exp. XXXX

PURPOSE OF FORM: A tenant or applicant who asks for protection under the Violence Against Women Act (VAWA), referred to in this form as “ you,” may use this form to fulfill a housing provider’s written request to certify status as a “victim” or document the incident(s) of “VAWA violence/abuse” as explained in the accompanying “Notice of Occupancy Rights Under the Violence Against Women Act,” Form HUD-5380 (VAWA Notice). For protections that depend on more than victim status or VAWA violence/abuse, you (the tenant or applicant) may be asked to provide other information or documentation to show that you qualify. However, you are not expected and cannot be asked or required—to claim, document, or prove victim status or VAWA violence/abuse other than as stated in the VAWA Notice.

This form is just one of your available options for responding to a housing provider’s written request for documentation of victim status or the incident(s) of VAWA violence/abuse. If you choose, you may submit one of the types of third-party documentation described in the VAWA Notice, in the section titled “What do I need to document that I am a victim?”.

NOTE: VAWA protects individuals and families regardless of a victim’s actual or perceived sexual orientation, gender identity, or marital status.

CONFIDENTIALITY: Your housing provider will keep strictly confidential any information you provide about the VAWA violence/abuse or the fact you are a victim, including the information on this form. This information can only be accessed by a person working for your housing provider if your housing provider explicitly authorizes that person’s access for a reason specifically called for under applicable law. This information will not be given to others or put in a database shared with others, unless your housing provider gets your written permission to do so for a limited time, is required to do so as part of an eviction or termination hearing or is required to do so by law.

Note: Any personal information you share in this form will not be collected nor maintained by HUD and will only be maintained by your Covered Housing Providers according to the confidentiality provisions above.

TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE, DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING

1. Date the written request for documentation of VAWA violence/abuse was received:

2. Name(s) of victim(s):

3. Name of applicant or tenant making (signing) this certification:

4. Name(s) of other member(s) of the household:

5. Name of the perpetrator (if known and can be safely disclosed):

6. _________________________________________________________

7. In your own words, briefly describe the incident(s) of domestic violence, dating violence, sexual assault, or stalking, and include the relevant location(s), date(s), time(s) and the victim’s relationship to the perpetrator (if known and can be safely disclosed):

(Please note that you may attach additional pages as needed)

Reasonable Accommodations: If you are an individual with a disability and may need a reasonable accommodation, please contact [INSERT CONTACT]. A reasonable accommodation related to this documentation may include, for example, allowing an oral statement instead of written documentation, or an extension of time to submit the requested documentation.

Regulatory VAWA definitions of domestic violence, dating violence, sexual assault, or stalking:

Domestic violence includes felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim by a person with whom the victim shares a child in common, by a person who lives with or has lived with the victim as a spouse or intimate partner, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction, or by any other person against an adult or youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction.

Dating violence means violence committed by a person:

1. Who is or has been in a social relationship of a romantic or intimate nature with the victim; and

2. Where the existence of such a relationship shall be determined based on a consideration of the following factors: (i) The length of the relationship; (ii) The type of relationship; and (iii) The frequency of interaction between the persons involved in the relationship.

Sexual assault means any nonconsensual sexual act proscribed by Federal, tribal, or State law, including when the victim lacks capacity to consent.

Stalking means engaging in a course of conduct directed at a specific person that would cause a reasonable person to:

1. Fear for the person's individual safety or the safety of others or

2. Suffer substantial emotional distress.

Certification of Applicant or Tenant: By signing below, I am certifying that the information provided on this form is true and correct to the best of my knowledge and recollection and that one or more members of my household is or has been a victim of domestic violence, dating violence, sexual assault, or stalking as described in the VAWA definitions above.

Signature

Signed on (Date

Public Reporting Burden for this collection of information is estimated to average 30 minutes per response. This includes the time for collecting, reviewing, and reporting. Comments concerning the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th Street, SW, Washington, DC 20410. Housing providers in programs covered by VAWA may request certification that the applicant or tenant is a victim of VAWA violence/abuse. A Federal agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid Office of Management and Budget control number.

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