Emergency Transfer Request For Victims Of Domestic Violence, Dating Violence, Sexual Assault, Or Stalking

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

EMERGENCY TRANSFER REQUEST FOR VICTIMS 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 housing assisted under a covered housing program, or if you are receiving
transitional housing or rental assistance under a covered housing program, you may use this form to request an
emergency transfer and certify that you qualify for an emergency transfer under the Violence Against Women Act
(“VAWA”). This form refers to domestic violence, dating violence, sexual assault, or stalking as “VAWA
violence/abuse.”
VAWA protects individuals and families regardless of a victim’s age or actual or perceived sexual orientation,
gender identity, sex, or marital status.
You may request an emergency transfer when:
1. You (or a household member) are a victim of VAWA violence/abuse;
2. You expressly request the emergency transfer; AND
3. EITHER
a. you reasonably believe that there is a threat of imminent harm from further violence, including
trauma, if you (or a household member) stay in the same dwelling unit; or
b. if you (or a household member) are a victim of sexual assault, either you reasonably believe
there is a threat of imminent harm from further violence, including trauma, if you (or a
household member) stay in the unit, or the sexual assault occurred on the premises and you
request an emergency transfer within 90 days (including holidays and weekend days) of when
that assault occurred.
A covered housing provider, in response to an emergency transfer request, should not evaluate whether you are in good
standing as part of the assessment or provision of an emergency transfer. Whether or not you are in good standing
does not impact your ability to request an emergency transfer under VAWA.
However, submitting this form does not necessarily mean that you will receive an emergency transfer. See your
covered housing provider’s VAWA Emergency Transfer Plan for more information about VAWA emergency transfers
and see “Notice of Occupancy Rights Under the Violence Against Women Act,” Form HUD-5380, for additional
housing rights you may be entitled to.
Am I required to submit any documentation to my covered housing provider? Your covered housing provider
may request documentation proving that you, or a household member, are a victim of VAWA violence/abuse, in
addition to completing this emergency transfer request form. The request can be met by completing and submitting the
VAWA Self-certification Form (Form HUD-5382), unless the covered housing provider receives conflicting
information about the VAWA violence/abuse. If you have third-party documentation that demonstrates why you are
eligible for an emergency transfer, you may, instead, choose to submit that documentation to your covered housing
provider. See “Notice of Occupancy Rights Under the Violence Against Women Act,” Form HUD-5380, for more
information.
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.

Page 1 of 3

Form HUD-5383
XXXX

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 need 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 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 TENANT REQUESTING AN EMERGENCY
TRANSFER
1. Name(s) of victim(s):_________________________________________________________________________
2. Your name (if different from victim’s): ___________________________________________________________
3. Name(s) of other household member(s):_________________________________________________________
___________________________________________________________________________________________
4. Name(s) of other household member(s) who would transfer with the victim: ___________________________

____________________________________________________________________________________
5. Name of the perpetrator (if known and can be safely disclosed): _______________________________________
6. Address of location from which the victim seeks to transfer:_________________________________________

____________________________________________________________________________________
7. Current Unit Size (# of bedrooms):_____________
8. 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

Page 2 of 3

Please List:_________________________________________________________________________

Form HUD-5383
XXXX

9. Anything else your housing provider should know to safely communicate with you?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
10. What features are requested for a safe unit? You may list here any information that would facilitate a suitable
transfer, such as accessibility needs, and a description of where it is safe or unsafe for you to live.
(Please note that the ability to provide an emergency transfer is based on unit availability.)
New Neighborhood

New Building

First Floor unit

Second Floor unit (and above)

Near an Exit

Well-lit hallways/walkways

24-hour Security

Accessible unit

Other: ___________________________________________________________________________________
___________________________________________________________________________________________
11. To approve your request for an emergency transfer, your covered housing provider may require that you provide
written documentation that you (or a household member) are a victim of VAWA violence/abuse. Your covered
housing provider must make this request for documentation in writing. You can choose to submit any one of the
following types of documentation:


Form HUD-5382 Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and
Alternate Documentation, which asks your name and the perpetrator’s name (if known and safe to
provide);



A document signed by a victim service provider, attorney, mental health professional, or medical
professional who has helped you address the VAWA violence/abuse. The professional must state “under
penalty of perjury” that he/she/they believe in the occurrence of the incident of VAWA violence/abuse and
that it is covered by VAWA. Both you and the professional must sign the statement;



A police, administrative, or court record (such as a protective order) that shows you (or a household
member) are a victim of VAWA violence/abuse; OR



If permitted by your covered housing provider, a statement or other evidence provided by you.

Certification of 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 I meet the conditions described on this form to qualify
for an emergency transfer.
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. Covered housing providers in programs covered by VAWA
may ask for a written request for an emergency transfer for a tenant who is a victim of domestic violence, dating violence, sexual assault, or stalking. Housing
providers may distribute this form to tenants and tenants may use it to request an emergency transfer. The information is subject to the confidentiality requirements
of VAWA. 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 3 of 3

Form HUD-5383
XXXX