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⚠️ Notice: This information collection may be referencing outdated material.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-50066 Certification of Domestic Violence, Dating Violence, or Stalking Form
HUD-50066 Certification of Domestic Violence, Dating Violence, or HUD-50066 rev 6-12.doc Form

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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 24 CFR 5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HUD-50066	Certification of Domestic Violence, Dating Violence, or Stalking	HUD-50066 rev 6-12.doc		Yes	Yes	Fillable Fileable

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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
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.