Certification of Domestic Violence, Dating Violence, or Stalking

Implementation of the Violence Against Women and Department of Justice Reauthorization Act of 2005

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2577-0249 can be found here:

Documents and Forms

Document Name Document Type
Form HUD-XXX Certification of Domestic Violence, Dating Violence, or Stalking Form and Instruction
HUD-XXX Certification of Domestic Violence, Dating Violence, or VAWA form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Certification of Domestic Violence, Dating Violence, or Stalking	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HUD-XXX	Certification of Domestic Violence, Dating Violence, or Stalking	VAWA form.doc		No		Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	4,800	4,800

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.