Flagstaff, AZ · Coconino County
Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking
This HUD form lets a Flagstaff housing applicant or tenant document victim status when requesting protections under the Violence Against Women Act.
What this form is
A housing applicant or tenant may use this form to respond to a covered housing provider’s written request for documentation of victim status or an incident of violence covered by the Violence Against Women Act. It asks for names, safe contact methods, and information about household members, followed by a signed certification. The form says providers must keep the information confidential.
Who needs it
A housing applicant or tenant seeking Violence Against Women Act protections may use this form if a covered housing provider requests written documentation.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer certifies the information is true and correct to the best of their knowledge and recollection, then dates it.
How to submit this form
- 1
Download the Form
Download the HUD-5382 certification form.
- 2
Complete the Form
Provide the requested names, safe contact methods, and communication information.
- 3
Sign and Date
Sign and date the certification affirming the information is true and correct to the best of your knowledge and recollection.
- 4
Submit to the City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What is the VAWA victim status certification form for?
- A housing applicant or tenant can use this form to respond to a covered housing provider’s written request for documentation of victim status or an incident covered by VAWA.
- What information does the form ask for?
- It asks for the victim’s name, household members, the perpetrator’s name if known and safe to disclose, safe contact methods, and any communication guidance.
- Do I need a notary for the VAWA certification form?
- No. The form has a signature and date line, but no notary block. The signer certifies the information is true and correct to the best of their knowledge and recollection.
- How do I submit the VAWA certification form?
- The form does not provide submission instructions. Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking doesn’t need a notary — but if you have another Flagstaff form that does, a commissioned online notary can help.