Legal VAWA Information Form

LEGAL VAWA INFORMATION FORM

Client Name:    Legal Representative / Service Provider:    Date Completed:

RECITALS

WHEREAS, the Client seeks confidential legal information, advice, or representation related to abuse or extreme cruelty and potential immigration relief under applicable federal statutes and related protections; and

WHEREAS, the Legal Representative / Service Provider is authorized to collect information, provide legal advice, prepare supporting documentation, and may, with the Client's informed consent, disclose information for the limited purposes set forth herein; and

WHEREAS, the parties wish to set forth the Client's statements, the scope of permitted uses of collected information, confidentiality limitations, and acknowledgments required for legal filings and advocacy.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. PURPOSE

The purpose of this form is to record the Client's factual statements, collect identifying and background information, obtain informed consent for limited disclosures, and document acknowledgments necessary to evaluate, prepare, and pursue any relief or services potentially available under applicable violence-related statutes and regulations.

2. DEFINITIONS

For purposes of this form: "Client" means the individual named above; "Provider" means the Legal Representative or Service Provider named above; "Confidential Information" means all verbal and written information provided by the Client to the Provider in connection with the matters described herein, subject to the exceptions in Section 4.

3. STATEMENT OF FACTS

Date of most recent incident:    Location of incident:

4. CONFIDENTIALITY; EXCEPTIONS

The Provider will maintain Confidential Information in accordance with applicable law on confidential communications and privilege. Communications with attorneys are subject to attorney-client privilege where applicable. The Client acknowledges the following exceptions to confidentiality:

(a) The Provider may disclose Confidential Information if required by court order, subpoena, mandatory reporting laws concerning imminent risk of harm to self or others, or other legal compulsion; (b) The Provider may disclose information with the Client's express written consent for the limited purposes described in Section 5; and (c) The Provider may prepare or file documents that contain factual statements from the Client where the Client has authorized such inclusion for an immigration petition, protective order, or other relief.

5. USE AND LIMITED DISCLOSURE CONSENT

The Client hereby authorizes the Provider to use and disclose Confidential Information solely for the following purposes (select all that apply):

Legal representation and preparation of petitions, declarations, and supporting exhibits.

Safety planning, shelter referral, and advocacy services.

Reporting of de-identified statistics to funders or oversight entities (no personal identifiers).

Release to specified third parties for case management or benefits (specify below if checked).

6. RETENTION, SECURITY, AND DATA HANDLING

The Provider will retain records containing Confidential Information in secure files. Unless otherwise required by law or court order, records will be retained for the period specified below and then securely destroyed or maintained according to professional standards.

7. NOTICES

All notices, requests, or other communications required or permitted under this form shall be in writing and delivered to the addresses or emails provided below. The Client and Provider may update contact information in writing at any time.

8. CERTIFICATION AND ACKNOWLEDGMENT

The Client certifies under penalty of perjury that the statements made in this form and any attachments are true and correct to the best of the Client's knowledge. The Client acknowledges that material misrepresentation may adversely affect any filing or representation and may have legal consequences. The Client further acknowledges that consent given pursuant to this form may be revoked in writing, except to the extent that the Provider has already relied upon such consent.

9. AMENDMENT; WAIVER; COUNTERPARTS

This form may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing signed by the waiving party. This form may be executed in counterparts, each of which constitutes an original and all of which constitute one instrument.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This form shall be governed by the laws of the state specified below without regard to conflict-of-law principles. This form constitutes the entire agreement between the Client and the Provider concerning the subject matter herein. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. SIGNATORY ACKNOWLEDGMENTS

Each signatory below represents and warrants that they have the authority to execute this form on behalf of the party indicated and that they have read, understand, and accept the terms contained herein.

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