**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:]{.underline}**

**Date Written Request Received By Family Member: [      ]{.underline}**

**Name of the Victim of Domestic Violence: [      ]{.underline}**

**Name(s) of other family members listed on the lease [      
]{.underline}**

**[      ]{.underline}**

**Name of the abuser: [      ]{.underline}**

**Relationship to Victim: [      ]{.underline}**

**Date the incident of domestic violence occurred: [    
 ]{.underline}**

**Time: [      ]{.underline}**

**Location of Incident: [      ]{.underline}**

**Name of victim: [    ]{.underline}**

**[ ]{.underline}**

**Description 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.