Form 5383 Emergency Transfer Request for Certain Victims of Sexual

EMERGENCY TRANSFER REQUEST FOR CERTAIN VICTIMS 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: If you or a member of your household is a victim of domestic violence, dating violence, sexual assault, or stalking, and you are seeking an emergency transfer for yourself or your household, you may use this form to request an emergency transfer and certify that you are eligible for an emergency transfer under the Violence Against Women Act of 1994, as amended (VAWA). This form refers to domestic violence, dating violence, sexual assault, or stalking as VAWA violence/abuse. Despite this law’s name, protections are not limited to women, and are available regardless of a victim’s sex, actual or perceived gender identity, sexual orientation, or marital status. Submitting this form does not necessarily mean that you will receive an emergency transfer. See your housing provider’s Emergency Transfer Plan for more information about emergency transfers. 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 below.

You may request an emergency transfer when:

1. You ( or a member of your household) are a victim of VAWA violence/abuse;

2. You specifically request the emergency transfer; and

3. (A) You reasonably believe* you (or a member of your household) will soon face more violence if you stay in your housing; or

(B) You (or a member of your household) are a victim of sexual assault that occurred on the premises and you request an emergency transfer within 90 days (including holidays and weekend days) after the date of that assault.

*Reasonable belief may stem from VAWA violence/abuse impacting a household member .

Submission of Documentation: If you have not already done so, your housing provider may require you to document that you, or a member of your household, are a victim of VAWA violence/abuse in addition to completing this emergency transfer request form. This can be met by a self-certification (Form HUD-5382) unless there is conflicting information. If you have third-party documentation that demonstrates why you are eligible for an emergency transfer, you may submit that documentation to your housing provider if you choose. See HUD-5380 (VAWA Notice) for more information.

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. In addition, your housing provider must keep your address strictly confidential to ensure that it is not disclosed to a person who committed or threatened to commit VAWA violence/abuse against you.

TO BE COMPLETED BY OR ON BEHALF OF THE TENANT REQUESTING A TRANSFER

1. Name(s) of Victim(s):

2. Your Name (if different from victim’s):

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

4. Name(s) of other household member(s) who would transfer with the victim:

5. Address of location from which the victim seeks to transfer:

Best Method of Contact:

Phone

Phone Number:

Is it okay to leave a voicemail? Yes No

Email

Email Address:

Mail

Mailing Address:

Other

Please list:

6. Name of the abuser (if known and can be safely disclosed):

7. Relationship of the abuser to the victim (if known and can be safely disclosed):

8. What features are requested for a safe unit? You may also list here any information that would facilitate a suitable transfer, such as accessibility needs, and a description of where it is safe/unsafe for you to live

(Please note, ability to provide is based on availability.)

New Neighborhood

New Building

First Floor unit

Second Floor unit (and above) Near an Exit

Well-lit hallways/walkways

24 Hour Security

Other:

9. NOTE: Your housing provider might, in certain circumstances, request written documentation that you are a victim of VAWA violence/abuse. This information can be documented as follows: You can decide which form to submit.

HUD Form 5382 Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and Alternate Documentation, which asks your name, the abuser’s name, if known and safe to provide, and a description of the incident(s).

A document signed by a victim service provider, attorney, mental health professional, or medical professional who has helped you address the VAWA violence/abuse. The professional must state “under penalty of perjury” that he/she/they believe in the occurrence of the incident of VAWA violence/abuse and that it is covered by VAWA. Both you and the professional must sign the statement.

A police, administrative, or court record (such as a protective order) that shows you (or a member of your household) are a victim of VAWA violence/abuse.

At the discretion of your housing provider, a statement or other documentation provided by you.

If permitted by your housing provider, a statement or other evidence provided by the tenant.

Certification of Tenant: By signing below, I certify that the following apply to me and my household:

1. I am requesting an emergency transfer.

AND

2. I believe there is a threat of imminent harm to myself or someone in my household if we stay in the same housing unit, AND/OR

I or a member of my household was sexually assaulted on the premises of my housing in the last 90 days.

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 ask for a written request for an emergency transfer for a tenant who is a victim of domestic violence, dating violence, sexual assault, or stalking. Housing providers may distribute this form to tenants and tenants may use it to request an emergency transfer. The information is subject to the confidentiality requirements of VAWA. 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.

Page 1 of 2 Form HUD-5383

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