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CERTIF CATION 07 D® a STIC II,S. De a�ei3t of �ens�o —IOg E1�iC DAT1IIgO ®ANC P m OMB Approval No. 2602.0204 and Urban Development Fop. 03/3112014 OR STA]LFING Office, of Housing 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 date. laformation provided is to be used by owners and management agents administering Section S project-based assistance under the United States Housing Act of 1937 (42 U.S.C. 1437) to request a t mm to certify that the individual is a victim of domestic violence, dating violence, or stalking. The information is subject to the confidentiality requirements of the HUD Reform Legislation. This agency may not collect this information, and you are not required to complete this farm unless it displays a currently valid OMB control number. Purpose of Form: The Violence Against Women and Justice Department Reauthorization Act of 2005 protects qualified tenants and family members of tenants who are victims of domestic violence, dating violence, or stalling (collectively "domestic violence') from being evicted or terminated from housing assistance based on acts bfsuch violence against them. Use ofForm: If you have been a victim of domestic violence, you m a family member on your behalf most complete and submit this certification form, or submit the information desedbed below under "Alternate Documentation," which may be provided in lieu of the certificationfomt, within 14 business days of receiving the written request fir this certification form by the owner or management agent The certification farm or alternate documentation must be returned to the person and the address specified in the written request for the red i5cation fi®. If the requested certification form or the information that may be provided in lieu of the certification firm is not received by the 14t1t business day or any extension of the date provided by the owner or management agent, none of the protections afforded to vietims of domestic business under the Section S project -based assistance progrdm.wlll apply. Distribution m issu ®ce of this form does not serve as awritten request for certif catam Alternate Documentation: In lies of this certification form (Orin addition to it), the following documentation may be provided: (1) A federal, state, tribal, temtorial, or local police or court record; or (2) Documentation signed by an employee, agent or volunteer of a victim service provider, an attorney or medical professional, from whom the victim has sought assistance in addressing the domestic violence, dating violence or stalking, or the effects of abuse, in which the professional attest under penalty of perjury (2s U.S.0 1746) to the professional's belief that the incident(s) in question are bona fide incidents of abuse, and the victim has signed or attested to the doommeatation. TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC V10LENCE: 1. Date written request is received from owner or management agent: _ 2. Name of victim: 3. Your name (if different): 4. Name(s) of other family members listed on the lease: 5. Name of the abuser: 6. Relationship of the abuser to the victim: 7. Date of incident: S. Time of incident: 9. Location of incident: (Page two must be completed and attached to this form.) Form HUD -91066 MOM