VAWA Certification Form

VAWA CERTIFICATION FORM

This VAWA Certification Form is executed between Applicant Name: and Housing Provider Name: (collectively, the Parties) effective as of: .

RECITALS

WHEREAS, Applicant asserts that Applicant has been the victim of domestic violence, dating violence, sexual assault, or stalking as defined under applicable federal law; and

WHEREAS, Applicant seeks the protections and accommodations available under the Violence Against Women Act (VAWA) from Housing Provider in connection with Applicant's tenancy or application for housing; and

WHEREAS, Housing Provider requires a written certification to document Applicant's request for VAWA protections and to establish procedures for confidentiality, documentation, and remedies.

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

1. DEFINITIONS

For purposes of this Certification, the following definitions apply: "VAWA protections" means the rights and remedies afforded to victims of domestic violence, dating violence, sexual assault, or stalking under federal law as implemented by Housing Provider policy. "Applicant" means the individual identified above who claims such victimization. "Housing Provider" means the entity identified above that manages, owns, or administers the housing.

2. CERTIFICATION OF VICTIM STATUS

Applicant hereby certifies that Applicant is or has been a victim of the following act(s) (check all that apply) and that the act(s) are the basis for the request for VAWA protections:

Type of incident: Domestic violence Dating violence Sexual assault Stalking

Date(s) of incident(s): . Location of incident(s): .

3. FACTUAL STATEMENT

Applicant shall provide a factual description of the circumstances supporting this certification. The following statement is made under penalty of law and is true and correct to the best of Applicant's knowledge:

4. SUPPORTING DOCUMENTATION

Applicant may provide one or more of the following as supporting documentation. Housing Provider will accept the form(s) indicated below and may, consistent with confidentiality obligations, retain copies for its records:

Police report or incident report Medical or forensic report Protective or restraining order Written affidavit from a qualified third party Other (describe):

5. CONFIDENTIALITY; LIMITED DISCLOSURE

Housing Provider shall treat all information submitted by Applicant as confidential to the extent required by law. Housing Provider may disclose information only as necessary to: (a) provide requested VAWA protections or accommodations; (b) comply with a court order or other legal requirement; or (c) protect the health or safety of residents where disclosure is necessary and only after reasonable attempts to notify Applicant. Housing Provider will redact social security numbers, dates of birth, and other sensitive identifying information from copies retained for administrative purposes where feasible.

6. FALSE STATEMENTS; PENALTIES

Applicant acknowledges that knowingly making a false statement or submitting false documentation for the purpose of obtaining VAWA protections may result in denial of the request and may expose Applicant to civil or criminal penalties under applicable law. Housing Provider reserves all rights to pursue remedies for material misrepresentation.

7. SCOPE OF PROTECTIONS AND RELIEF

If Applicant's certification satisfies Housing Provider's requirements, Housing Provider will, consistent with its policies and applicable law, provide appropriate relief which may include lease bifurcation, emergency transfer, reasonable accommodations, or other remedies reasonably calculated to ensure Applicant's safety and housing stability. Any such relief shall be documented in a separate written agreement or addendum.

8. NOTICES

Notices related to this Certification shall be delivered to the Parties at the addresses set forth below by personal delivery, certified mail, or other method providing evidence of delivery. Notice is effective upon receipt.

9. COOPERATION

The Parties agree to cooperate in good faith to implement protections or accommodations authorized by this Certification. Applicant agrees to provide supplemental information or access to documentation reasonably requested by Housing Provider to effectuate protections, subject to confidentiality protections herein.

10. AMENDMENT; WAIVER; COUNTERPARTS

This Certification may be amended only by a writing signed by both Parties. No waiver by either Party of any breach of this Certification shall be effective unless in writing. This Certification may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Certification shall be governed by and construed in accordance with the laws of the state in which the housing is located, without regard to conflict of law principles. This Certification constitutes the entire agreement between the Parties with respect to the subject matter herein and supersedes all prior understandings, written or oral. If any provision of this Certification is held invalid or unenforceable, the remainder of this Certification shall remain in full force and effect.

12. EXECUTION

By signing below, Applicant certifies under penalty of perjury that the information provided in this form is true and correct to the best of Applicant's knowledge. Housing Provider acknowledges receipt of this Certification and agrees to apply its policies and legal obligations consistent with Applicant's request.

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