Agenda Packet_2025-07-15 - Laserfiche WebLink

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EXHIBIT 1 Confidentiality: All information provided to your housing provider concerning the incident(s) of domestic violence, dating violence, sexual assault, or stalking, and concerning your request for an emergency transfer shall be kept confidential. Such details shall not be entered into any shared database. Employees of your housing provider are not to have access to these details unless to grant or deny VAWA protections or an emergency transfer to you. Such employees may not disclose this information to any other entity or individual, except to the extent that disclosure is: (i) consented to by you in writing in a time -limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of assistance; or (iii) otherwise required by applicable law. TO BE COMPLETED BY OR ON BEHALF OF THE PERSON REQUESTING A TRANSFER 1. Name of victim requesting an emergency transfer: 2. Your name (if different from victim's) 3. Name(s) of other family member(s) listed on the lease: 4. Name(s) of other family member(s) who would transfer with the victim: 5. Address of location from which the victim seeks to transfer: 6. Address or phone number for contacting the victim: 7. Name of the accused perpetrator (if known and can be safely disclosed): 8. Relationship of the accused perpetrator to the victim: 9. Date(s), Time(s) and location(s) of incident(s): 10. Is the person requesting the transfer a victim of a sexual assault that occurred in the past 90 days on the premises of the property from which the victim is seeking a transfer? If yes, skip question 11. If no, fill out question 11. 11. Describe why the victim believes they are threatened with imminent harm from further violence if they remain in their current unit. 12. If voluntarily provided, list any third -party documentation you are providing along with this notice: Pag - — 025 City Council 743 5 2 25