HAPP Violence Against Women Act HUD-5382 Form

10 CERTIFICATION OF DOMESTIC VIOLENCE , DATING VIOLENCE , SEXUAL ASSAULT , OR STALKING Confidentiality Note Any personal information you share in this form will be maintained by your covered housing provider according to the confidentiality provisions below Purpose of Form If you are a tenant of or applicant for housing assisted under a covered housing program , or if you are applying for or receiving transitional housing or rental assistance under a covered housing program , and ask for protection under the Violence Against Women Act “ VAWA ” , you may use this form to comply with a covered housing providers request for written documentation of your status as a victim ” This form is accompanied by a Notice of Occupancy Rights Under the Violence Against Women Act , Form HUD - 5380 VAWA protects individuals and families regardless of a victim’s age , sex , or marital status You are not expected and cannot be asked or required to claim , document , or prove victim status or VAWA violence abuse other than as stated in Notice of Occupancy Rights Under the Violence Against Women Act , Form HUD - 5380 This form is one of your available options for responding to a covered housing provider’s written request for documentation of victim status or the incident s of VAWA violence abuse If you choose , you may submit one of the types of third - party documentation described in Form HUD - 5380 , in the section titled , “ What do I need to document that I am a victim ” Your covered housing provider must give you at least 14 business days weekends and holidays do not count to respond to their written request for this documentation Will my information be kept confidential Whenever you ask for or about VAWA protections , your covered housing provider must keep any information you provide about the VAWA violence abuse or the fact you or a household member are a victim , including the information on this form , strictly confidential This information should be securely and separately kept from your other tenant files This information can only be accessed by an employee agent of your covered housing provider if 1 access is required for a specific reason , 2 your covered housing provider explicitly authorizes that person’s access for that reason , and 3 the authorization complies with applicable law This information will not be given to anyone else or put in a database shared with anyone else , unless your covered housing provider 1 gets your written permission to do so for a limited time , 2 is required to do so as part of an eviction or termination hearing , or 3 is required to do so by law In addition , your covered housing provider must keep your address strictly confidential to ensure that it is not disclosed to a person who committed or threatened to commit VAWA violence abuse against you or a household member What if I require this information in a language other than English To read this in Spanish or another language , please contact [ INSERT COVERED HOUSING PROVIDER’S CONTACT INFORMATION ; FOR HOPWA PROVIDERS – INSERT GRANTEE NAME AND CONTACT INFORMATION ] or go to [ INSERT WEBSITE , IF APPLICABLE ] You can read translated VAWA forms at https wwwhudgov program_offices administration hudclips forms hud5 a # 4 If you speak or read in a language other than English , your covered housing provider must give you language assistance regarding your VAWA protections for example , oral interpretation and or written translation Can I request a reasonable accommodation If you have a disability , your covered housing provider must provide reasonable accommodations to rules , policies , practices , or services that may be necessary to allow you to equally benefit from VAWA protections for example , giving you more time to submit documents or assistance with filling out forms You may request a reasonable accommodation at any time , even for the first time during an eviction If a provider is denying a specific reasonable accommodation because it is not reasonable , your covered housing provider must first engage in the interactive process with you to identify possible alternative accommodations Your covered housing provider must also ensure effective communication with individuals with disabilities PageNeed further help For additional information on VAWA and to find help in your area , visit https wwwhudgov vawa To speak with a housing advocate , contact [ ENTER CONTACT INFO FOR LOCAL ADVOCACY AND LEGAL AID ORGANIZATIONS ] TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE , DATING VIOLENCE , SEXUAL ASSAULT , OR STALKING 1 Name s of victim s _____________________________________________________________________ 2 Your name if different from victim’s ________________________________________________________ 3 Name s of other member s of the household ________________________________________________ ________________________________________________________________________________________ 4 Name of the perpetrator if known and can be safely disclosed ___________________________________ 5 What is the safest and most secure way to contact you You may choose more than one If any contact information changes or is no longer a safe contact method , notify your covered housing provider Phone Phone Number ____________________________________________________ Safe to receive a voicemail Yes No E - mail E - mail Address ____________________________________________________ Safe to receive an email Yes No Mail Mailing Address _________________________________________________________ Safe to receive mail from your housing provider Yes No Other Please List ______________________________________________________________ 6 Anything else your housing provider should know to safely communicate with you ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________PageApplicable definitions of domestic violence , dating violence , sexual assault , or stalking Domestic violence includes felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim , by a person with whom the victim shares a child in common , by a person who lives with or has lived with the victim as a spouse or intimate partner , by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction , or by any other person against an adult or youth victim who is protected from that persons acts under the domestic or family violence laws of the jurisdiction Spouse or intimate partner of the victim includes a person who is or has been in a social relationship of a romantic or intimate nature with the victim , as determined by the length of the relationship , the type of the relationship , and the frequency of interaction between the persons involved in the relationship Dating violence means violence committed by a person 1 Who is or has been in a social relationship of a romantic or intimate nature with the victim ; and 2 Where the existence of such a relationship shall be determined based on a consideration of the following factors i The length of the relationship ; ii The type of relationship ; and iii The frequency of interaction between the persons involved in the relationship Sexual assault means any nonconsensual sexual act proscribed by Federal , tribal , or State law , including when the victim lacks capacity to consent Stalking means engaging in a course of conduct directed at a specific person that would cause a reasonable person to 1 Fear for the persons individual safety or the safety of others or 2 Suffer substantial emotional distress Certification of Applicant or Tenant By signing below , I am certifying that the information provided on this form is true and correct to the best of my knowledge and recollection , and that one or more members of my household is or has been a victim of domestic violence , dating violence , sexual assault , or stalking as described in the applicable definitions above Signature Date Public Reporting Burden for this collection of information is estimated to average 20 minutes per response This includes the time for collecting , reviewing , and reporting Comments concerning the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer , QDAM , Department of Housing and Urban Development , 451 7th Street , SW , Washington , DC 20410 Housing providers in programs covered by VAWA may request certification that the applicant or tenant is a victim of VAWA violence abuse A Federal agency may not collect this information , and you are not required to complete this form , unless it displays a currently valid Office of Management and Budget control number Page