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Certification of Domestic Violence, U.S. Department of Housing OMB Approval No.2577-0249 <br /> Dating Violence, and Urban Development Exp.(07/31/2017) <br /> Office of Public and Indian Housing <br /> Sexual Assault, or Stalking <br /> Purpose of Form: The Violence Against Women Reauthorization Act of 2013 ("VAWA")protects qualified tenants, participants, and applicants, and affiliated <br /> individuals, who are victims of domestic violence, dating violence, sexual assault, or stalking from being denied housing assistance, evicted, or terminated from <br /> housing assistance based on acts of such violence against them. <br /> Use of Form: This is an optional form. A PHA,owner or manager presented with a claim for continued or initial tenancy or assistance based on status as a victim of <br /> domestic violence, dating violence, sexual assault, or stalking(herein referred to as "Victim")has the option to request that the victim document or provide written <br /> evidence to demonstrate that the violence occurred. The Victim has the option of either submitting this form or submitting third-party documentation,such as: <br /> (1)A record of a Federal,State,tribal,territorial,or local law enforcement agency(e.g.police),court,or administrative agency;or <br /> (2)Documentation signed by the Victim and signed by an employee,agent or volunteer of a victim service provider,an attorney,a medical professional,or a <br /> mental health professional from whom the Victim has sought assistance relating to domestic violence, dating violence, sexual assault, or stalking, or the <br /> effects of abuse, in which the professional attests under penalty of perjury(28 U.S.C. 1746)that he or she believes that the incident of domestic violence, <br /> dating violence,sexual assault,or stalking is grounds for protection under 24 Code of Federal Regulations(CFR)§5.2005 or 24 CFR§5.2009. <br /> If this form is used by the Victim, the Victim must complete and submit it within 14 business days of receiving it from the PHA,owner or manager. This form must <br /> be returned to the person and address specified in the written request for the certification. If the Victim does not complete and return this form(or provide third-party <br /> verification)by the 14th business day or by an extension of the date provided by the PHA,manager or owner,the Victim cannot be assured s/he will receive VAWA <br /> protections. <br /> If the Victim submits this form or third-party documentation as listed above,the PHA,owner or manager cannot require any additional evidence from the Victim. <br /> Confidentiality: All information provided to a PHA, owner or manager concerning the incident(s)of domestic violence,dating violence,sexual assault,or stalking <br /> relating to the Victim (including the fact that an individual is a victim of domestic violence,dating violence,sexual assault,or stalking)shall be kept confidential by <br /> the PHA, owner or manager,and such information shall not be entered into any shared database. Employees of the PHA,owner,or manager are not to have access to <br /> these details unless to afford or reject VAWA protections to the Victim; and may not disclose this information to any other entity or individual,except to the extent <br /> that disclosure is:(i)requested or consented to by the Victim in writing;(ii)required for use in an eviction proceeding;or(iii)otherwise required by applicable law. <br /> TO BE COMPLETED BY THE VICTIM OF DOMESTIC VIOLENCE,DATING VIOLENCE,SEXUAL ASSAULT,OR <br /> STALKING: <br /> Date Written Request Received by Victim: <br /> Name of Victim: <br /> Names of Other Family Members Listed on the Lease: <br /> Name of the Perpetrator: * <br /> *Note: The Victim is required to provide the name of the perpetrator only if the name of the perpetrator is safe to provide,and is <br /> known to the victim. <br /> Perpetrator's Relationship to Victim: <br /> Date(s)the Incident(s)of Domestic Violence,Dating Violence,Sexual Assault or Stalking Occurred: <br /> Location of Incident(s): <br /> HAPPY Software, Inc. Page 1 of 2 form HUD-50066 <br /> DM 01/31/2017 (7/2014) <br /> 1...11..11..11..11 ILII 11.1..1..1.1..1.1..1.1.11..1 <br />