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

CERTIFICATION OF DOMESTIC U.S. Department of Housing OMB Approval No. xxxx-xxxx

VIOLENCE, DATING VIOLENCE, and Urban Development Exp. (xx/xx/xxxx

OR STALKING Office of Public and Indian Housing

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: A family member must complete and submit this certification, or the information that may be provided in lieu of the certification, within 14 business days of receiving the written request for this certification by the PHA, owner or manager. The certification or alternate documentation must be returned to the person and address specified in the written request for the certification. If the family member has not provided the requested certification or the information that may be provided in lieu of the certification by the 14th business day or any extension of the date provided by the PHA, manager and owner, none of the protections afforded to victims of domestic violence, dating violence or stalking (collectively “domestic violence”) under the Section 8 or public housing programs apply.

Note that a family member 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 victim 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.

___________________________________________________________________________________________

TO BE COMPLETED BY THE VICTIM OF DOMESTIC VIOLENCE:

Date Written Request Received By Family Member: _______________________________________________

Name of the Victim of Domestic Violence: __________________________________________________________

Name(s) of other family members listed on the lease _________________________________________________

______________________________________________________________________________________________

Name of the abuser: ____________________________________________________________________________

Relationship to Victim: _________________________________________________________________________

Date the incident of domestic violence occurred: ___________________________________________________

Time: _________________________________

Location of Incident: __________________________________________________________________________

Name of victim: ____________________________________________________________________________________

D

Description of Incident:

[INSERT TEXT LINES HERE]

escription 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.

2

form HUD-XXXXX

(X/XX/2006)