Certification Of Domestic Violence, Dating Violence, Sexual Assault, Or Stalking

U.S. Department of Housing and Urban Development
OMB Approval No. 2577-0286
Exp. XXXX

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 provider's 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 or actual or perceived sexual
orientation, gender identity, 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://www.hud.gov/program_offices/administration/hudclips/forms/hud5a#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

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Form HUD-5382
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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.
Need further help? For additional information on VAWA and to find help in your area, visit
https://www.hud.gov/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:

E-mail

No

E-mail Address:____________________________________________________

Safe to receive an email:

Mail

Yes

Yes

No

Mailing Address:_________________________________________________________

Safe to receive mail from your housing provider:

Other

Yes

No

Please List:______________________________________________________________

6. Anything else your housing provider should know to safely communicate with you?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

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Applicable 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 person's 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 person's 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.

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