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Administrative Plan 7/1/2025 Page 16-68 <br />Confidentiality: All information provided to your housing provider concerning the incident(s) of <br />domestic violence, dating violence, sexual assault, or stalking, and concerning your request for an <br />emergency transfer shall be kept confidential. Such details shall not be entered into any shared database. <br />Employees of your housing provider are not to have access to these details unless to grant or deny VAWA <br />protections or an emergency transfer to you. Such employees may not disclose this information to any <br />other entity or individual, except to the extent that disclosure is: (i) consented to by you in writing in a <br />time-limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of <br />assistance; or (iii) otherwise required by applicable law. <br />TO BE COMPLETED BY OR ON BEHALF OF THE PERSON REQUESTING A TRANSFER <br />1. Name of victim requesting an emergency transfer: ______________________________________ <br />2. Your name (if different from victim’s)_________________________________________________ <br />3. Name(s) of other family member(s) listed on the lease:____________________________________ <br />___________________________________________________________________________________ <br />4. Name(s) of other family member(s) who would transfer with the victim:____________________ <br />____________________________________________________________________________________ <br />5. Address of location from which the victim seeks to transfer: _______________________________________ <br />6. Address or phone number for contacting the victim:____________________________________ <br />7. Name of the accused perpetrator (if known and can be safely disclosed):___________________ <br />8. Relationship of the accused perpetrator to the victim:___________________________________ <br />9. Date(s), Time(s) and location(s) of incident(s):___________________________________________ <br />_____________________________________________________________________________________ <br />10. Is the person requesting the transfer a victim of a sexual assault that occurred in the past 90 <br />days on the premises of the property from which the victim is seeking a transfer? If yes, skip <br />question 11. If no, fill out question 11. ______________ <br />11. Describe why the victim believes they are threatened with imminent harm from further <br />violence if they remain in their current unit. <br />___________________________________________________________________________________ <br />_____________________________________________________________________________________ <br />12. If voluntarily provided, list any third-party documentation you are providing along with this <br />notice: ___________________________________________________________________ <br />EXHIBIT 1