Hud 5382 - Domestic Violence, Dating Violence (Page 2 of 2) in pdf

TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,

DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING

1. Date the written request is received by victim: _________________________________________

2. Name of victim: ___________________________________________________________________

3. Your name (if different from victim’s):________________________________________________

4. Name(s) of other family member(s) listed on the lease:___________________________________

___________________________________________________________________________________

5. Residence of victim: ________________________________________________________________

6. Name of the accused perpetrator (if known and can be safely disclosed):____________________

__________________________________________________________________________________

7. Relationship of the accused perpetrator to the victim:___________________________________

8. Date(s) and times(s) of incident(s) (if known):___________________________________________

_________________________________________________________________

10. Location of incident(s):_____________________________________________________________

In your own words, briefly describe the incident(s):

______________________________________________________________________________________

This is to certify that the information provided on this form is true and correct to the best of my

______________________________________________________________________________________

knowledge and recollection, and that the individual named above in Item 2 is or has been a victim of

______________________________________________________________________________________

domestic violence, dating violence, sexual assault, or stalking. I acknowledge that submission of false

information could jeopardize program eligibility and could be the basis for denial of admission,

______________________________________________________________________________________

termination of assistance, or eviction.

______________________________________________________________________________________

Signature __________________________________Signed on (Date) ___________________________

______________________________________________________________________________________

_____________________________________________________________________________

Public Reporting Burden: The 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. The

information provided is to be used by the housing provider to request certification that the applicant or

tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is

subject to the confidentiality requirements of VAWA. This 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.

Form HUD-5382

(12/2016)

Hud 5382 - Domestic Violence, Dating Violence Page 2