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Administrative Plan 7/1/2025 Page 16-63 <br />TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE, <br />DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING <br />1. Date the written request is received by victim: _________________________________________ <br />2. Name of victim: ___________________________________________________________________ <br />3. Your name (if different from victim’s):________________________________________________ <br />4. Name(s) of other family member(s) listed on the lease:___________________________________ <br />___________________________________________________________________________________ <br />5. Residence of victim: ________________________________________________________________ <br />6. Name of the accused perpetrator (if known and can be safely disclosed):____________________ <br />__________________________________________________________________________________ <br />7. Relationship of the accused perpetrator to the victim:___________________________________ <br />8. Date(s) and times(s) of incident(s) (if known):___________________________________________ <br />_________________________________________________________________ <br />10. Location of incident(s):_____________________________________________________________ <br /> <br /> <br /> <br /> <br /> <br /> <br />This is to certify that the information provided on this form is true and correct to the best of my <br />knowledge and recollection, and that the individual named above in Item 2 is or has been a victim of <br />domestic violence, dating violence, sexual assault, or stalking. I acknowledge that submission of false <br />information could jeopardize program eligibility and could be the basis for denial of admission, <br />termination of assistance, or eviction. <br /> <br />Signature __________________________________Signed on (Date) ___________________________ <br />Public Reporting Burden: The public reporting burden for this collection of information is estimated to <br />average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The <br />information provided is to be used by the housing provider to request certification that the applicant or <br />tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is <br />subject to the confidentiality requirements of VAWA. This agency may not collect this information, and <br />you are not required to complete this form, unless it displays a currently valid Office of Management and <br />Budget control number. <br />In your own words, briefly describe the incident(s): <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />______________________________________________________________________________________ <br />_____________________________________________________________________________ <br /> <br />EXHIBIT 1