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Description ofheident: <br />In your own words, describe the incident (Attach more sheets if needed. Initial and number each attachment.): <br />This is to certify that the information provided is true and coaect, and that the individual named above in Item 2 is a <br />victim of domestic violence, dating violence, or stalking. The incident(s) in question is a bona fide incident(s) of <br />such actual or threatened abuse. I acknowledge that submission of false information obuld jeopardize program <br />eligibility and could be the basis for termination of Section 8 project -based assistance or eviction from assisted <br />properly. <br />Signature Executed on (Date) <br />Pursuant to 42 U.S.C. 1437f(ee)(2)(A), all information provided to an owner or management agent related to the <br />incident(s) of domestic violence, dating violence or stalking, including the fact that an individual is a victim of <br />domestic violence, dating violence or stalking shall be retained in confidence by the owner or management agent and <br />shall neither be entered into any shared database nor provided to any related entity, except to the extent that such <br />disclosure is: <br />(1) Requested or consented to by the victim in writing; <br />(2) Required for use in an eviction proceeding or termination of assistance; or <br />(3) Otherwise required by applicable law <br />Form HM -91066 <br />(9!1008) <br />