Professional Certification of Domestic Violence, Dating Violence, Sexual Assault or Stalking

This top section is to be completed by the program participant seeking VAWA protections.

Program Participant: [WRITE PARTICIPANT’S NAME]

Date: [WRITE DATE]

Provider of Housing or Rental Assistance: [WRITE NAME OF PROVIDER]

Deadline to Submit This Form (if applicable): [WRITE DEADLINE]

VAWA Protection Requested:

[CHOOSE ONE OF THE FOLLOWING]

Defense of eviction, termination, or denial   

Emergency Transfer

Removal of household member   

Other: [DESCRIBE]

What is VAWA and how does it apply to housing and rental assistance programs?  The Violence Against Women Act (“VAWA”) protects applicants, tenants, and program participants in certain HUD programs from being evicted, denied housing assistance, or terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or stalking against them.  It also provides special housing protections, like emergency transfers to alternative rental units.  Despite the name of this law, VAWA protection is available to victims of domestic violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual orientation.

Why am I being asked to complete this form?  The person asking you to complete this form is seeking VAWA protections from a housing provider or rental assistance provider.  The provider of housing or rental assistance has asked or may ask the person to document this abuse, and this form may be used to evaluate the request for VAWA housing protections. 

Who should fill out this form?  An employee, agent, or volunteer of a victim service provider, an attorney, or medical professional, or a mental health professional (collectively, “professional”) who provided assistance to the program participant relating to domestic violence, dating violence, sexual assault, or stalking, or the effects of abuse. 

How long do I have to fill out this form?  Once a provider of housing or rental assistance requests documentation to support the program participants request for VAWA protections, the program participant must respond within 14 days.  An extension may be requested, protections requested may be unavailable until documentation is provided.

Confidentiality:  All information provided on this form is confidential and will not be entered into any shared database.  Only staff of the provider of housing or rental assistance who are evaluating the request for VAWA protections have access to this form, and such employees may not disclose this information to any other entity or individual, except to the extent that disclosure is: (i) consented to the program participant in writing in a time-limited release; or (ii) otherwise required by applicable law.

Fax or mail this completed form to: [WRITE FAX NUMBER OR ADDRESS]

 

To be completed by the professional:

1.  Your name: [WRITE PROFESSIONAL’S NAME]

2.  Attach your business card or provide your contact information here: [WRITE PROFESSIONAL’S CONTACT INFORMATION]

3.  What is your relationship with the program participant requesting VAWA protections? [DESCRIBE RELATIONSHIP]

4.  Under penalty of perjury, do you believe that the program participant requesting this form was the victim of incident or incidents of domestic violence, dating violence, sexual assault, or stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or “stalking,” as defined by HUD’s regulations at 24 CFR 5.2003?  Your attestation is limited to your belief that the victim’s self-reporting or other evidence presented to you is credible and satisfies the regulatory definitions provided by 5.2003, included below.

[CHOOSE ONE OF THE FOLLOWING]

Yes

No

I lack sufficient information to form a belief.

 

24 CFR 5.2003 provides the following definitions:

• 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 is cohabitating with or has cohabitated 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 receiving grant monies, 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. The term “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.

Signature: [PROFESSIONAL SIGNS HERE]

Date: [WRITE DATE]

 

I, [WRITE PARTICIPANT NAME] authorize [WRITE NAME OF PROVIDER] to release this form to the provider listed above. I certify that the information I provided to the service provider completing this form is true and correct to the best of my knowledge and recollection, and that I was or have been a victim of domestic violence, dating violence, sexual assault, or stalking. I acknowledge that submission of this form based on false information could jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or eviction.

Signature of Program Participant: [PARTICIPANT SIGNS HERE]

Date: [WRITE DATE]

 

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