Form Hud-5382 - Certification Of Domestic Violence, Dating Violence, Sexual Assault, Or Stalking, And Alternate Documentation Page 2
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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):___________________________________________
_________________________________________________________________
9. 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)
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