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_____________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road l Concord, New Hampshire 03301-6000 l (603) 224-9221
Fax (603) 228-1387 l l TDD (800) 545-1833 X118 l Equal Opportunity Provider and Employer
Prior to starting your application, take a moment to carefully read
through the required items below. If your application is incomplete
or any of these required items are missing, IT WILL NOT BE
PROCESSED.
• Please write the specific property/properties you would like to
apply for. Do not write “All”.
• You must include a copy of each household member’s Social
Security card; or something legal with the full number on it.
• All household members over the age of 18 must report all asset
and income information.
• When completing the income portion, be sure to report all gross
weekly or monthly income (before taxes or deductions).
• All household members over the age of 18 must sign and date
the application and all forms with the application.
• You must provide complete landlord contact information (full
name, mailing address, and phone number; email, and/or fax if
available to expedite your application).
o If you do not have any rental history, please visit our
website to print a Co-Signer Application.
www.hodgescompanies.com
Apartment Communities
Affordable Housing scroll to the bottom of the page
where you will find our Co-Signer Application. Anyone over
the age of 18 can apply to be a co-signer unless they are
already on a current lease with Hodges.
If you have any questions, please feel free to contact our office. Thank
you.
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
1
Lakes Region Community Developers
C/O The Hodges Companies
201 Loudon Road, Concord, NH 03301
Tel: 1-800-742-4686 Fax: 603-228-1387
PRINT & RETAIN FOR YOUR RECORDS
Dear Applicant,
Thank you for your interest in Lakes Region Community Developers permanently affordable
housing professionally managed by The Hodges Companies. Your completed application;
along with copies of Social Security cards for each household member, should be sent
directly to our property management company, The Hodges Companies, 201 Loudon
Road, Concord, NH 03301. Faxed Applications are not accepted. An original signature
must be received.
Once received, your application will be quickly verified for eligibility. If it is determined you are
eligible, you will be placed on the Lakes Region Community Developers waiting list
maintained by Hodges. Hodges will advise you if it is determined you are not eligible.
When there is an opening and your name is at the top of the list, Hodges will contact you to
verify you are still interested in housing with Lakes Region Community Developers. Once you
have indicated your continued interest, Hodges will begin the process of verifying your income
and checking prior landlord references. This process can take approximately two weeks or
less; with your cooperation. Hodges will contact you if additional information is needed. As
soon as your application is processed, Hodges will contact you directly. Meanwhile, please
keep Hodges updated if things change for you, such as phone numbers or addresses.
Lakes Region Community Developers has strict income guidelines imposed by its lenders.
These guidelines must be followed in the qualification process. This means that although you
may qualify for some of Lakes Region Community Developers properties, you may not qualify
for other properties with different guidelines.
Although we understand your need for a prompt response, we do ask for your patience during
this process. Thank you.
Proudly & Professionally Managed by
201 Loudon Road, Concord, NH 03301
(603) 224-9221
Toll Free 1-800-742-4686
TDD 1-800-545-1833 X118
housing@hodgescompanies.com
Revised 01/18
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
2
For Office Use Only
Date Sent _____________
Date Rec’d ____________
Time Rec’d ____________
Applicant Questionnaire
Applying for Property (s)
Household Information
List all household members that are applying to live in this apartment with you.
Name
First, Middle Initial, Last
Relationship to
Head of Household
Social Security
Number
Birthdate
Month, Date, Year
Self
Current Address:
Maiden Name:
(1) Daytime Phone:
(2) Evening Phone
(1) __________________________________
(2)
(3) Email:
(4) How did you
hear about us?:
(3)
(4)________________________
YES
NO
1.
Do you expect any additions to the household within the next twelve months?
Name & Relatio
nship:
Explanation:
ο
2.
Is there anyone living with you now who won’t be living with you at this property?
Name & Relationship:
Explanation:
3. Do you have full custody of your child(ren)?
Explanation:
4.
Are there any absent household members who under normal conditions would live with you? (For
example, a household member away in the military.)
Explanation:
ο
ο ο
ο
ο
ο
ο
Does your household have or anticipate having any pets other than those used as service animals?
5.
ο ο
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
3
Rental History
YES
NO
6.
Have you or anyone else named on this application filed for bankruptcy?
Explanation:
7.
Have you or anyone else named on this application been convicted of a misdemeanor or felony?
Explanation:
8.
Have you or anyone else named on this application been convicted for dealing or manufacturing
illegal drugs?
Explanation:
9.
Have you or anyone else named on this application been convicted of property damage?
Explanation:
10.
Have you or anyone else named on this application been evicted from a rental unit of any type
including an apartment, home, mobile home or trailer?
Explanation:
Housing References
List the your past THREE housing references. (If additional space is required, a blank piece of paper.)
Landlord’s Name/Address
Your Address
Own/Rent
Dates
Name:
Own
From:
Address:
Rent
To:
Amount
$ __________________
Phone:
( )
Name:
Own
From:
Address:
Rent
To:
Phone:
( )
Name:
Own
From:
Address:
Rent
To:
Amount
Phone:
( )
Personal Reference
List a personal reference other than a relative.
Name:
Address:
Phone:
Relationship:
Years Known:
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
4
Vehicle Identification
List vehicle information for all vehicles that are owned or operated by any household member.
Tag/License Plate #
State Issued
Make/Model/Year
Vehicle #1:
Vehicle #2:
Emergency Contact
List someone in the area that is not already on the application.
Name:
Address:
Phone:
Relationship:
Years Known:
Income Information
Income is counted for anyone 18 or older (unless legally emancipated). However, if the income is unearned income such as a grant or
benefit, it is counted for all household members including minors.
Include all income anticipated for the next 12 months.
Do YOU or ANYONE in your household receive OR expect to receive income from:
YES
NO
11.
Employment wages or salaries? (Include overtime, tips, bonuses, commissions and payments received in cash.)
Household Member
Name of Company
Amount
12.
Self-employment or Net Income from a Business? (Include overtime, tips, bonuses, commissions and payments
received in cash.)
Household Member
Type of Business
Amount
13.
Regular pay as a member of the Armed Forces/Military Pay?
Household Member
Base Name & Branch
Amount
14.
Unemployment benefits, disability pay or workman’s compensation?
Household Member
Contact Person
Amount
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
5
15.
Public Assistance, General Relief or Temporary Aid for Needy Families (TANF, OAA, APTD)?
Household Member
Contact Person
Amount
16.
(a)
Child support or Alimony?
(We must count court-ordered support whether or not it is received unless legal action has been taken to remedy. We must also
count support that is not court-ordered rather received directly from payor.)
Household Member
Payor
Amount
(b)
How is the support received? (Check all that apply)
Child Support Enforcement
Agency
Name of Agency:
Court of Law
Name of Court:
Directly from Individual
Name of Person:
Other
Explain:
(c)
If money is not actually received, are you taking legal action to remedy?
Explanation:
17.
Social Security, SSI, SSD or any other payments from the Social Security Administration?
Household Member
SSA Office
Amount
18.
Regular payments from a Veteran’s benefit, pension, retirement benefit or annuities?
Household Member
Source of Benefit
Amount
19.
Regular payments from a severance package or Long Term Care Insurance Policies?
Household Member
Source of Benefit
Amount
20.
Regular payments from any type of settlement? (For example, insurance settlements.)
Household Member
Source of Benefit
Amount
21.
Regular gifts or payments from anyone outside of the household?
(This includes anyone supplementing your income or paying any of your bills.)
Household Member
Source of Benefit
Amount
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
6
22.
Educational grants, scholarships, or other student benefits?
Household Member
Source of Benefit
Amount
23.
Regular payments from lottery winnings or inheritances?
Household Member
Source of Benefit
Amount
24.
Regular payments from rental property or other types of real estate transactions?
Household Member
Source of Benefit
Amount
25.
Resident Services Stipend ($200 or more a month) or any other income sources or types not listed?
Household Member
Source of Benefit
Amount
26.
Do you or any other household members expect any changes to your income in the next 12
months?
Explanation:
Asset Information:
Include all assets held and the income derived from the asset. INCLUDE ALL ASSETS HELD BY ALL HOUSEHOLD MEMBERS
INCLUDING MINORS.
Do YOU or ANYONE in your household have:
YES
NO
27.
Checking, savings, debit card account?
Household Member
Bank Name
Amount
28.
CDs, money market accounts, savings bonds or treasury bills?
Household Member
Bank Name
Amount
29.
Stocks, bonds or securities, or capital gains?
Household Member
Source of Benefit
Amount
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
7
30.
Trust funds or whole/universal life?
Household Member
Source of Benefit
Amount
31.
Pensions, IRAs, Keoghs, Annuities or other retirement accounts?
Household Member
Source of Benefit
Amount
32.
Cash on hand over $500? Lump sum or One-Time Cash Receipts?
Household Member
Source of Benefit
Amount
33.
Real estate, rental property, land contracts/contract for deeds, capital gains or other real estate
holdings?
(This includes your personal residence, mobile homes, vacant land, farms, vacation homes or commercial property.)
Household Member
Source of Benefit
Amount
34.
Personal property held as an investment?
(This includes paintings, coin or stamp collections, artwork, collector or show cars, and antiques. This does not include your personal
belongings such as your car, furniture or clothing.)
Household Member
Source of Benefit
Amount
35.
A safe deposit box? Any other assets not listed above?
Household Member
Bank Name
Amount
36.
Have you or any other household members disposed of or given away any asset(s) for LESS than
fair market value within the past 2 years?
Household Member:
Amount:
Explanation:
Applicant Status
The following questions pertain to specific eligibility requirements of the Housing Credit Program.
YES
NO
37.
Are you or any other ADULT household member(s) claiming zero income?
Household Member:
Explanation:
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
8
38.
Are any household members (INCLUDING MINORS) currently a part or full-time student(s) or
expect to be in the next 12 months?
Household Member(s):
39.
Do you or any ADULT household member now require a live-in care attendant in order to live
independently?
Name of Attendant:
Relationship (if any):
40.
Will your household be receiving Section 8 or any other rental assistance at time of move-in
(Examples: NHHFA, Laconia Housing, Ozanam Place)?
Name of Agency:
Contact Person:
41.
Will your household be eligible or are you applying to receive Section 8 rental assistance in the
next 12 months?
Expected Date:
Name of Agency:
Contact Person:
________________________________________________________________
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
9
Signature Clause
I understand that management is relying on this information to prove my household’s eligibility for the Housing Credit
Program. I certify that all information and answers to the above questions are true and complete to the best of my
knowledge. I consent to release the necessary information to determine my eligibility. I understand that providing false
information or making false statements may be grounds for denial of my application. I also understand that such action may
result in criminal penalties.
I authorize my consent to have management verify the information contained in this application for purposes of proving my
eligibility for occupancy. I will provide all necessary information including source names, addresses, phone numbers,
account numbers where applicable and any other information required for expediting this process. I understand that my
occupancy is contingent on meeting management’s resident selection criteria and the Housing Credit Program requirements.
Penalties for misusing this consent: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly
making false or fraudulent statements to any department of the United States Government. HUD, the PHA and any owner (or any employee of
HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the
consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly
or willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a
misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action
for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the
unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at
42 U.S.C. 208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
Authorization-This release may be used for 15 months from the date of signature.
I/we do hereby authorize Hodges Companies and its staff to contact any agencies, offices, employers, financial institutions,
pension/retirement accounts, etc, credit bureaus, landlords, criminal records, or professional references for the purpose of
verifying the information I/we have provided on the application. The information provided will be used solely for the
determination of my/our eligibility and admission to the housing I/we are applying for and the information that is supplied
will be kept confidential.
All ADULT household members over the age of 18 must sign below:
Signature Date
Signature Date
Signature Date
Have you or any member listed on the application served in the military? ___ Yes ___ No
Are you or any member listed on the application a Veteran? ___ Yes __ No
If yes, list the names _______________________________________________________________________
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
10
The information regarding race, national origin, and sex designation
solicited on this application is requested in order to assure the Federal
Government, acting through the USDA, Rural Development, that
Federal Laws prohibiting discrimination against tenant applicants on
the basis of race, color, national origin, religion, sex, familial status,
age, and handicap are complied with. You are not required to furnish
this information, but are encouraged to do so. This information will not
be used in evaluating your application or to discriminate against you in
any way. However, we would like to make you aware that, if you do
not provide this information, the owner/rental agent is required to note
race/national origin and sex based on visual observation or surname.
Ethnicity: ( ) Hispanic or Latino ( ) Not Hispanic or Latino
Race: (mark one or more) ( ) American Indian or Alaskan Native ( ) Black or
African American ( ) Asian
( ) Native Hawaiian or Other Pacific Islander ( ) White ( ) Other
Gender: ( ) Male ( ) Female
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc.
10/31/97
All Rights Reserved
6.0
11
TENANT RELEASE AND CONSENT
I/We ______________________________________ , the undersigned hereby authorize all persons or
companies in the categories listed below to release information regarding employment, income and/or assets for
purposes of verifying information on my/our apartment rental application. I/We authorized release of information
without liability to the owner/manager of the apartment community listed below, and/or the state housing
development agency or it’s service provider.
INFORMATION COVERED
I/We understand that the previous or current information regarding we/us may be needed. Verifications and
inquires that may be requested include but are not limited to: personal identity, student status, employment
income, assets, and medical or child care allowances. I/We understand that this authorization cannot be used to
obtain information about me/us that is not pertinent to my eligibility for and continued participation as a Qualified
Tenant.
GROUPS OR INDIVIDUALS THAT MAY BE ASKED
The groups or individuals that may be asked to release the above information include, but are not limited to:
Past and Present Employers Criminal Checks Veterans Administration
Support and Alimony Providers State Unemployment Agencies Retirement Systems
Educational Institutions Social Security Administration Medical Providers
Banks/Financial Institutions Current and Previous Landlords Child Care Providers
Public Housing Agencies State and Federal Agencies Credit Agencies
CONDITIONS
I/We agree that a photocopy of the authorization may be used for the purposes stated above. The original of this
authorization is on file and will stay in effect for 15 months from the date signed. I/We understand that I/We have
a right to review this file and correct any information that is incorrect.
SIGNATURES
(
)
________
(
) (
)
Tenant Signature (Print Name) Date
(
) (
) (
)
Co-Tenant Signature (Print Name) Date
_________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 10/31/97
All Rights Reserved 6.0
12
Disclaimer
I hereby make application for an apartment and certify that this information is correct. I
authorize Lakes Region Community Developers (LRCD) property management company, The
Hodges Companies (Hodges), to contact any references that I have listed. By signing this
application, the applicants understand that this information may be shared with members of the
Lakes Region Rental Association.
I also authorize Hodges to obtain consumer reports, and any other information necessary for the
purpose of evaluating my application. I understand that such information may include, but is not
limited to, credit history, civil and criminal information, records of arrest, rental history,
employment/salary details, vehicle records, licensing records, and/or any other necessary
information. I understand that subsequent consumer reports may be obtained and utilized under
this authorization in connection with an update, renewal, extension, or collection in connection
with the rental or lease of a residence for which this application was made.
I hereby expressly release LRCD, Hodges, and any procurer or furnisher of information, from
any liability what-so-ever in the use, procurement, or furnishing of such information and
understand that my application information may be provided to various local, state, and/or
federal government agencies, including without limitation, various law enforcement agencies.
_______________________________ _________________________
Signature of Applicant Date
_______________________________ _________________________
Signature of Applicant Date
_____________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
Applicant Certification
I/We, ____________________, acknowledges Receipt of a copy of
the following:
• HUD 5380 VAWA Notice of Occupancy Rights Under the
VAWA Act
• HUD-5382 Certification of Domestic Violence, Dating
Violence, Sexual Assault, or Stalking and Alternate
Documentation
________________________ _______________
Signature Date
________________________ _______________
Signature Date
NOTICE OF OCCUPANCY RIGHTS UNDER
THE VIOLENCE AGAINST WOMEN ACT
U.S. Department of Housing and Urban Development
OMB Approval No. 2577-0286
Expires 06/30/2017
Form HUD-5380
(12/2016)
Hodges Development Corporation
1
Notice of Occupancy Rights under the Violence Against Women Act
2
To all Tenants and Applicants
The Violence Against Women Act (VAWA) provides protections for victims of domestic
violence, dating violence, sexual assault, or stalking. VAWA protections are not only available
to women, but are available equally to all individuals regardless of sex, gender identity, or sexual
orientation.
3
The U.S. Department of Housing and Urban Development (HUD) is the Federal
agency that oversees that Section 8 Rental Assistance is in compliance with VAWA. This
notice explains your rights under VAWA. A HUD-approved certification form is attached to this
notice. You can fill out this form to show that you are or have been a victim of domestic
violence, dating violence, sexual assault, or stalking, and that you wish to use your rights under
VAWA.”
Protections for Applicants
If you otherwise qualify for assistance under HUD Section 8, you cannot be denied admission or
denied assistance because you are or have been a victim of domestic violence, dating violence,
sexual assault, or stalking.
Protections for Tenants
1
The notice uses HP for housing provider but the housing provider should insert its name where HP is used.
HUD’s program-specific regulations identify the individual or entity responsible for providing the notice of
occupancy rights.
2
Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual
orientation.
3
Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national
origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made
available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or
marital status.
2
Form HUD-5380
(12/2016)
If you are receiving assistance under HUD Section 8, you may not be denied assistance,
terminated from participation, or be evicted from your rental housing because you are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking.
Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,
dating violence, sexual assault, or stalking by a member of your household or any guest, you
may not be denied rental assistance or occupancy rights under HUD Section 8 solely on the basis
of criminal activity directly relating to that domestic violence, dating violence, sexual assault, or
stalking.
Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom
you stand in the place of a parent or guardian (for example, the affiliated individual is in your
care, custody, or control); or any individual, tenant, or lawful occupant living in your household.
Removing the Abuser or Perpetrator from the Household
HODGES DEVELOPMENT CORPORATION may divide (bifurcate) your lease in order to
evict the individual or terminate the assistance of the individual who has engaged in criminal
activity (the abuser or perpetrator) directly relating to domestic violence, dating violence, sexual
assault, or stalking.
If HODGES DEVELOPMENT CORPORATION chooses to remove the abuser or perpetrator,
HODGES DEVELOPMENT CORPORATION may not take away the rights of eligible tenants
to the unit or otherwise punish the remaining tenants. If the evicted abuser or perpetrator was the
sole tenant to have established eligibility for assistance under the program, HODGES
DEVELOPMENT CORPORATION must allow the tenant who is or has been a victim and other
household members to remain in the unit for a period of time, in order to establish eligibility
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
3
Form HUD-5380
(12/2016)
under the program or under another HUD housing program covered by VAWA, or, find
alternative housing.
In removing the abuser or perpetrator from the household, HODGES DEVELOPMENT
CORPORATION must follow Federal, State, and local eviction procedures. In order to divide a
lease, HODGES DEVELOPMENT CORPORATION may, but is not required to, ask you for
documentation or certification of the incidences of domestic violence, dating violence, sexual
assault, or stalking.
Moving to Another Unit
Upon your request, HODGES DEVELOPMENT CORPORATION may permit you to move to
another unit, subject to the availability of other units, and still keep your assistance. In order to
approve a request, HODGES DEVELOPMENT CORPORATION may ask you to provide
documentation that you are requesting to move because of an incidence of domestic violence,
dating violence, sexual assault, or stalking. If the request is a request for emergency transfer, the
housing provider may ask you to submit a written request or fill out a form where you certify that
you meet the criteria for an emergency transfer under VAWA. The criteria are:
(1) You are a victim of domestic violence, dating violence, sexual assault, or
stalking. If your housing provider does not already have documentation that you
are a victim of domestic violence, dating violence, sexual assault, or stalking, your
housing provider may ask you for such documentation, as described in the
documentation section below.
(2) You expressly request the emergency transfer. Your housing provider may
choose to require that you submit a form, or may accept another written or oral
request.
4
Form HUD-5380
(12/2016)
(3) You reasonably believe you are threatened with imminent harm from
further violence if you remain in your current unit. This means you have a
reason to fear that if you do not receive a transfer you would suffer violence in the
very near future.
OR
You are a victim of sexual assault and the assault occurred on the premises
during the 90-calendar-day period before you request a transfer. If you are a
victim of sexual assault, then in addition to qualifying for an emergency transfer
because you reasonably believe you are threatened with imminent harm from
further violence if you remain in your unit, you may qualify for an emergency
transfer if the sexual assault occurred on the premises of the property from which
you are seeking your transfer, and that assault happened within the 90-calendar-day
period before you expressly request the transfer.
HODGES DEVELOPMENT CORPORATION will keep confidential requests for emergency
transfers by victims of domestic violence, dating violence, sexual assault, or stalking, and the
location of any move by such victims and their families.
HODGES DEVELOPMENT CORPORATION’s emergency transfer plan provides further
information on emergency transfers, and HODGES DEVELOPMENT CORPORATION must
make a copy of its emergency transfer plan available to you if you ask to see it.
Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,
Sexual Assault or Stalking
HODGES DEVELOPMENT CORPORATION can, but is not required to, ask you to provide
documentation to “certify” that you are or have been a victim of domestic violence, dating
5
Form HUD-5380
(12/2016)
violence, sexual assault, or stalking. Such request from HODGES DEVELOPMENT
CORPORATION must be in writing, and HODGES DEVELOPMENT CORPORATION must
give you at least 14 business days (Saturdays, Sundays, and Federal holidays do not count) from
the day you receive the request to provide the documentation. HODGES DEVELOPMENT
CORPORATION may, but does not have to, extend the deadline for the submission of
documentation upon your request.
You can provide one of the following to HODGES DEVELOPMENT CORPORATION as
documentation. It is your choice which of the following to submit if HODGES
DEVELOPMENT CORPORATION asks you to provide documentation that you are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking.
• A complete HUD-approved certification form given to you by HODGES
DEVELOPMENT CORPORATION with this notice, that documents an incident of
domestic violence, dating violence, sexual assault, or stalking. The form will ask for your
name, the date, time, and location of the incident of domestic violence, dating violence,
sexual assault, or stalking, and a description of the incident. The certification form
provides for including the name of the abuser or perpetrator if the name of the abuser or
perpetrator is known and is safe to provide.
• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or
administrative agency that documents the incident of domestic violence, dating violence,
sexual assault, or stalking. Examples of such records include police reports, protective
orders, and restraining orders, among others.
• A statement, which you must sign, along with the signature of an employee, agent, or
volunteer of a victim service provider, an attorney, a medical professional or a mental
health professional (collectively, “professional”) from whom you sought assistance in
click to sign
signature
click to edit
click to sign
signature
click to edit
6
Form HUD-5380
(12/2016)
addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of
abuse, and with the professional selected by you attesting under penalty of perjury that he
or she believes that the incident or incidents of domestic violence, dating violence, sexual
assault, or stalking are grounds for protection.
• Any other statement or evidence that HODGES DEVELOPMENT CORPORATION has
agreed to accept.
If you fail or refuse to provide one of these documents within the 14 business days, HODGES
DEVELOPMENT CORPORATION does not have to provide you with the protections contained
in this notice.
If HODGES DEVELOPMENT CORPORATION receives conflicting evidence that an incident
of domestic violence, dating violence, sexual assault, or stalking has been committed (such as
certification forms from two or more members of a household each claiming to be a victim and
naming one or more of the other petitioning household members as the abuser or perpetrator),
HODGES DEVELOPMENT CORPORATION has the right to request that you provide third-
party documentation within thirty 30 calendar days in order to resolve the conflict. If you fail or
refuse to provide third-party documentation where there is conflicting evidence, HODGES
DEVELOPMENT CORPORATION does not have to provide you with the protections contained
in this notice.
Confidentiality
HODGES DEVELOPMENT CORPORATION must keep confidential any information you
provide related to the exercise of your rights under VAWA, including the fact that you are
exercising your rights under VAWA.
7
Form HUD-5380
(12/2016)
HODGES DEVELOPMENT CORPORATION must not allow any individual administering
assistance or other services on behalf of HODGES DEVELOPMENT CORPORATION (for
example, employees and contractors) to have access to confidential information unless for
reasons that specifically call for these individuals to have access to this information under
applicable Federal, State, or local law.
HODGES DEVELOPMENT CORPORATION must not enter your information into any shared
database or disclose your information to any other entity or individual. HODGES
DEVELOPMENT CORPORATION, however, may disclose the information provided if:
• You give written permission to HODGES DEVELOPMENT CORPORATION to release
the information on a time limited basis.
• HODGES DEVELOPMENT CORPORATION needs to use the information in an
eviction or termination proceeding, such as to evict your abuser or perpetrator or
terminate your abuser or perpetrator from assistance under this program.
• A law requires HODGES DEVELOPMENT CORPORATION or your landlord to release
the information.
VAWA does not limit HODGES DEVELOPMENT CORPORATION’s duty to honor court
orders about access to or control of the property. This includes orders issued to protect a victim
and orders dividing property among household members in cases where a family breaks up.
Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or
Assistance May Be Terminated
You can be evicted and your assistance can be terminated for serious or repeated lease violations
that are not related to domestic violence, dating violence, sexual assault, or stalking committed
against you. However, HODGES DEVELOPMENT CORPORATION cannot hold tenants who
8
Form HUD-5380
(12/2016)
have been victims of domestic violence, dating violence, sexual assault, or stalking to a more
demanding set of rules than it applies to tenants who have not been victims of domestic violence,
dating violence, sexual assault, or stalking.
The protections described in this notice might not apply, and you could be evicted and your
assistance terminated, if HODGES DEVELOPMENT CORPORATION can demonstrate that not
evicting you or terminating your assistance would present a real physical danger that:
1) Would occur within an immediate time frame, and
2) Could result in death or serious bodily harm to other tenants or those who work on the
property.
If HODGES DEVELOPMENT CORPORATION can demonstrate the above, HODGES
DEVELOPMENT CORPORATION should only terminate your assistance or evict you if there
are no other actions that could be taken to reduce or eliminate the threat.
Other Laws
VAWA does not replace any Federal, State, or local law that provides greater protection for
victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to
additional housing protections for victims of domestic violence, dating violence, sexual assault,
or stalking under other Federal laws, as well as under State and local laws.
Non-Compliance with The Requirements of This Notice
You may report a covered housing provider’s violations of these rights and seek additional
assistance, if needed, by contacting or filing a complaint with HUD, Norris Cotton Federal
Building, 275 Chestnut Street, 4
th
Floor, Manchester, NH 03101-2487.
For Additional Information
You may view a copy of HUD’s final VAWA rule at
https://www.federalregister.gov/documents/2014/10/20/2014-24284/violence-against-women-act
9
Form HUD-5380
(12/2016)
Additionally, HODGES DEVELOPMENT CORPORATION must make a copy of HUD’s
VAWA regulations available to you if you ask to see them.
For questions regarding VAWA, please contact HUD, Norris Cotton Federal Building, 275
Chestnut Street, 4
th
Floor, Manchester, NH 03101-2487.
For help regarding an abusive relationship, you may call the National Domestic Violence Hotline
at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may
also contact Crisis Center of Central NH, PO Box 1344, Concord, NH 03302-1344,
1-866-841-6229 (Crisis Line), 603-225-7376 (Office).
For tenants who are or have been victims of stalking seeking help may visit the National Center
for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-
programs/stalking-resource-center.
For help regarding sexual assault, you may contact Bridges: Domestic & Sexual Violence
Support, PO Box 217, Nashua, NH 03061-0217, 603-883-3044 (Crisis Line), 603-672-9833
(Milford office), 603-889-0858 (Nashua Office).
Victims of stalking seeking help may contact Voices Against Violence, PO Box 53 Plymouth,
NH 03264, 603-536-1659 (Crisis Line), 603-536-5999 (Office).
Attachment: Certification form HUD-5382
10
Form HUD-5380
(12/2016)
Attachment to VAWA
The following is a list of some of the organizations that offer assistance to victims of domestic violence,
dating violence, sexual assault, and/or stalking:
1) Voices Against Violence
PO Box 53
Plymouth, NH 03264
603-536-1659 (Crisis Line)
603-536-5999 (Office)
2) New Beginnings Without Violence and Abuse
PO Box 622
Laconia, NH 03247
1-866-644-3574 (Domestic Violence)
1-800-277-5570 (Sexual Assault)
603-528-6511 (Office)
3) Crisis Center of Central NH
PO Box 1344
Concord, NH 03302-1344
1-866-841-6229 (Crisis Line)
603-225-7376 (Office)
4) YWCA Crisis Service
72 Concord Street
Manchester, NH 03101
603-668-2299 (Crisis Line)
603-625-5785 (Manchester Office)
5) Bridges: Domestic & Sexual Violence Support
PO Box 217
Nashua, NH 03061-0217
603-883-3044 (Crisis Line)
603-672-9833 (Milford office)
603-889-0858 (Nashua Office)
CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286
DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017
DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING,
AND ALTERNATE DOCUMENTATION
Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and
program participants in certain HUD programs from being evicted, denied housing assistance, or
terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or
stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic
violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual
orientation.
Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your
housing provider may give you a written request that asks you to submit documentation about the incident
or incidents of domestic violence, dating violence, sexual assault, or stalking.
In response to this request, you or someone on your behalf may complete this optional form and submit it
to your housing provider, or you may submit one of the following types of third-party documentation:
(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an
attorney, or medical professional, or a mental health professional (collectively, “professional”) from
whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or
stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the
professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or
stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or
“stalking” in HUD’s regulations at 24 CFR 5.2003.
(2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or
administrative agency; or
(3) At the discretion of the housing provider, a statement or other evidence provided by the applicant
or tenant.
Submission of Documentation: The time period to submit documentation is 14 business days from the date that you
receive a written request from your housing provider asking that you provide documentation of the occurrence of
domestic violence, dating violence, sexual assault, or stalking. Your housing provider may, but is not required to,
extend the time period to submit the documentation, if you request an extension of the time period. If the requested
information is not received within 14 business days of when you received the request for the documentation, or any
extension of the date provided by your housing provider, your housing provider does not need to grant you any of the
VAWA protections. Distribution or issuance of this form does not serve as a written request for certification.
Confidentiality: All information provided to your housing provider concerning the incident(s) of domestic
violence, dating violence, sexual assault, or stalking shall be kept confidential and 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 to you, and 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 VICTIM OF DOMESTIC VIOLENCE,
DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING
1. Date the written request is received by victim: _________________________________________
2. Name of victim: ___________________________________________________________________
3. Your name (if different from victim’s):________________________________________________
4. Name(s) of other family member(s) listed on the lease:___________________________________
___________________________________________________________________________________
5. Residence of victim: ________________________________________________________________
6. Name of the accused perpetrator (if known and can be safely disclosed):____________________
__________________________________________________________________________________
7. Relationship of the accused perpetrator to the victim:___________________________________
8. Date(s) and times(s) of incident(s) (if known):___________________________________________
_________________________________________________________________
10. Location of incident(s):_____________________________________________________________
In your own words, briefly describe the incident(s):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
This is to certify that the information provided on this form is true and correct to the best of my knowledge
and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,
dating violence, sexual assault, or stalking. I acknowledge that submission of false information could
jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or
eviction.
Signature __________________________________Signed on (Date) ___________________________
Form HUD-5382
12/2016)
Public Reporting Burden: The public reporting burden for this collection of information is estimated to average 1
hour per response. This includes the time for collecting, reviewing, and reporting the data. The information provided is
to be used by the housing provider to request certification that the applicant or tenant is a victim of domestic violence,
dating violence, sexual assault, or stalking. The information is subject to the confidentiality requirements of VAWA.
This agency may not collect this information, and you are not required to complete this form, unless it displays a
currently valid Office of Management and Budget control number.
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Completed 22 March 2022

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