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EXHIBIT 1 <br />Exhibit TPS-3: EXAMPLE OF A VICTIM SERVICES PROVIDER'S CERTIFICATION <br />Attachment 4 of Notice PIH 2O21-15: Example of a Victim Services Provider's Certification <br />Emergency Housing Voucher (EHV) <br />SAMPLE HUMAN TRAFFICKING CERTIFICATION <br />Purpose of Form: <br />The Victims of Trafficking and Violence Protection Act of 2000 provides assistance to victims of <br />trafficking making housing, educational health care, job training and other Federally -funded social <br />service programs available to assist victims in rebuilding their lives. <br />Use of This Optional Form: <br />In response to this request, the service provider may complete this form and submit it to the Public <br />Housing Agency (PHA) to certify eligibility for EHV assistance. <br />Confidentiality: All information provided to the service provider concerning the incident(s) of human <br />trafficking shall be kept confidential and such details shall not be entered into any shared database. <br />Employees of the PHA will not have access to these details, and such employees may not disclose <br />this information to any other entity or individual, except to the extent that disclosure is: (i) consented to <br />by you in writing in a time -limited release; (ii) required for use in an eviction proceeding or hearing <br />regarding termination of assistance; or (iii) otherwise required by applicable law. <br />TO BE COMPLETED ON BEHALF OF HUMAN TRAFFICKING SURVIVOR <br />EHV Applicant Name: <br />This is to certify that the above named individual or household meets the definition for <br />persons who are fleeing or attempting to flee human trafficking under section 107(b) of the <br />Trafficking Victims Protection Act of 2000. <br />Immediately prior to entering the household's current living situation, the person(s) named above <br />was/were residing in: <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(s) named above is/has been a victim of human <br />trafficking. I acknowledge that submission of false information could jeopardize program eligibility and <br />could be the basis for denial of admission, termination of assistance, or eviction. <br />Authorized Agency Representative Signature: Date: <br />Page TPS-36 Administrative Plan 7/l/2025 <br />City Council 5 - 936 7/15/2025 <br />