Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking

Purpose of this form

This form is for use by tenants or applicants who are seeking to use protections available under the Violence Against Women Act (VAWA) and who have been notified by Landlord of an alleged lease violation or denial of admission. By completing this form, you are stating under penalty of perjury that you, or an affiliated individual in your household, have been a victim of domestic violence, dating violence, sexual assault, or stalking.

Time to respond

You have 14 business days from the date Landlord asked you for documentation to return this form (or other accepted documentation). Landlord may extend the 14-day window in writing; absent an extension, failure to respond may waive your VAWA defense. If you need additional time, ask Landlord in writing for an extension.

Form contents (mirrors HUD Form 5382)

1. Date the written request was issued by Landlord:  

2. Name of victim:  

3. Your name (if different from the victim):  

4. Name(s) of other family member(s) listed on the lease:  

5. Residence of the victim (same as your residence unless otherwise noted):  

6. Name of accused person, if known and safe to disclose:  

7. Relationship of the accused to victim:  

8. Date(s) and times (if known) of incident(s):  

9. Brief description of the incident(s):

This certification, signed and dated below, is submitted as the victim's claim

I certify that the information provided on this form is true and correct to the best of my knowledge and recollection, and that the individual identified as the victim of the abuse in this form has experienced an incident of domestic violence, dating violence, sexual assault, or stalking.

I acknowledge that submission of false information may result in adverse action by the lease housing provider, and that lease violations not premised on the act of abuse cannot be remedied by submitting this form, although I may have other defenses.

I acknowledge that Landlord may keep this form, and any other documentation submitted under VAWA, confidential, and that Landlord may share the information only as permitted by 24 C.F.R. § 5.2007(b)(4).

Signature of victim:  

Printed name:  

Date signed:  

Public reporting burden

The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD may not collect this information and you are not required to complete this form unless it displays a currently valid OMB Control Number. The OMB number for HUD Form 5382 is 2577-0286.

Where to get help

• National Domestic Violence Hotline: 1-800-799-7233 (1-800-799-SAFE) or text "START" to 88788. Available 24/7, free, confidential.
• National Sexual Assault Hotline: 1-800-656-4673 (1-800-656-HOPE). 24/7, free, confidential.
• Strong Hearts Native Helpline (for Indigenous survivors): 1-844-7NATIVE (1-844-762-8483).
• The U.S. Department of Justice Office on Violence Against Women: justice.gov/ovw.

This is a plain-language reference copy of HUD Form 5382 as reissued 06/2017 (OMB 2577-0286). The official PDF from HUD controls in any conflict. Rentari.ai is not a law firm; you should consult a legal-aid organization or attorney for advice about your specific situation. If you are in immediate danger, call 911.