PathStone Management Corporation

6 Prince Street
Rochester, New York 14607
Phone: (585) 546-6340
Fax: (585) 546-4825
TDD: 1-800-545-1833
www.pathstonecommunities.org

Dear Applicant,

Thank you for your interest in Skyview Park Apartments, our newest senior community for
those 55 years of age and older. We have taken part of the old “Irondequoit Mall” and
transformed it into an incredible senior living community for your enjoyment.

Skyview Park Apartments offers 145 one bedroom apartments and 12 two bedroom apartments
with a host of state-of-the-art amenities including in-unit washer/dryer, storage, community
room, fitness center, multiple elevators, roll-in showers (in select units), extra handicapped
parking, and a beautifully landscaped courtyard with gazebo. Skyview Park is a non-smoking
community. Included in the monthly rent is heat and hot water. Residents pay their electric.

Eight units will be fully adapted and move-in ready for persons who have mobility impairment,
and 3 units will be fully accessible, adapted and move-in ready for persons who have a hearing
or vision impairment.

We have partnered with Rochester Regional Health to offer 78 units to the Frail Elderly. These
units will receive onsite supportive services from Rochester Regional Health. To be considered
Frail Elderly, seniors age 55 and older must be enrolled in Medicaid and require assistance with
one or more activities of daily living.

An application for Skyview Park Apartments is attached to this packet. Applications can be
returned via e-mail to [email protected] or dropped-off/mailed to:

6 Prince Street,
Rochester, NY 14607

A drop slot is located in the main door of the office. Due to COVID-19 our office is currently
closed to the public for walk-ins. Applicants can also apply online at Skyviewparkapts.org.

Income and occupancy restrictions do apply. For more information on these restrictions, and to
review rental rates, please see the attached flyer. A housing lottery will be held on Tuesday June
8, 2021 at 2pm via Zoom. The application deadline to be included in the lottery is May 18, 2021.
The Zoom link to attend this event virtually is: https://zoom.us/j/94456826094

We predict that move-ins will take place in Fall of 2021. However, this can change based on
construction. For any questions, please contact us at [email protected].

Sincerely,

Jamie Brown
Property Marketing Coordinator
PathStone Corporation
 Skyviewparkapts.org (585) 546-6340
TDD (800) 545-1833 [email protected]
200 Medley Centre Parkway, Irondequoit 14622

55+ Senior Community

1 & 2 Bedroom Apartments
Fitness Center
Central Air Conditioning
In-Unit Washer & Dryer
PathStone has partnered with Rochester Regional Health to
Outdoor Patios with Grill Station
offer onsite supportive services to 78 units within Skyview
Community Garden Space Park Apartments. These units will be reserved for the Frail
Roll-In/Walk-In Showers Available Elderly. To be considered Frail Elderly you must be a senior
who is enrolled in Medicaid and need assistance with
Visit Our Website For a Full List of Amenities & to Apply personal care/or community living, such as shopping,
laundry, medication management, nutrition, etc. Additional
Applications may also be picked up outside of 6 Prince Street,
requirements apply. Contact us for more information.
Rochester, NY 14607 or found on NyHousingSearch.gov

The housing lottery will be held on

June 8, 2021 at 2pm via Zoom.

https://zoom.us/j/94456826094
The application deadline to be
included in the lottery is May 18, 2021

Income and Occupancy Limits are Subject to Change

 Skyview Park Apartments
200 Medley Centre Parkway, Irondequoit, NY 14622

Senior Community
55 years of age and older

Resident Application
RETURN APPLICATION TO: FOR OFFICE USE ONLY
Please mail completed applications to our office located at the
address below. You may also drop applications off in the mail slot at Date Time
the same location.
Application Accepted by
Due to COVID-19 our office is closed to the public for walk-ins.

PathStone Management Corporation

Fill out below if applicant is a referral
6 Prince Street from Rochester Regional Health:
Rochester, NY 14607
□ Frail Elderly
Phone 585-546-6340
TDD 800-545-1833
FAX 585-546-4852 Rochester Regional Health Signature:
Applications may also be e-mailed to: [email protected]

INFORMATION SOLICITED ON THIS APPLICATION IS REQUESTED BY THE APARTMENT OWNER IN ORDER TO

ASSURE THAT FEDERAL LAWS PROHIBITING DISCRIMINATION AGAINST TENANT APPLICATIONS ON THE BASIS OF
RACE, COLOR, NATIONAL ORIGIN, RELIGION, SEX, MARITAL STATUS, AGE AND HANDICAP ARE COMPLIED WITH.
THIS INFORMATION WILL NOT BE USED TO DISCRIMINATE AGAINST YOU. WE ARE AN EQUAL HOUSING
OPPORTUNITY ORGANIZATION.
PathStone complies with federal and state disability laws and makes reasonable accommodations for applicants and residents with
disabilities. If a reasonable accommodation is needed to participate in any part of the application, interview process as well as at any
time during housing please contact the property manager to submit the request.

The Violence Against Women Act (VAWA) provides protection for victims of domestic violence, dating violence, sexual assault and
stalking. These protections are available to all individuals regardless of sex, gender identity or sexual orientation. If you are seeking
VAWA protections please complete HUD form 5382 attached or contact the property manager.

Please review your application carefully. If any questions are not answered, the application may
be deemed incomplete and could be returned to you.
Applicant 1 Applicant 2
Name Name
Address Address_
City City
Zip Code Zip Code
Telephone Telephone
Age _ Sex Age Sex
Date of Birth Date of Birth
Social Security# Social Security#
Email Email
FAMILY COMPOSITION (Persons to reside in apartment in addition to above named):

Name Relationship Birth Date Social Security #

1.
2.
3.
4.

Rev. 03/2021
BEDROOM SIZE REQUESTED
□ (1) One Bedroom □ (2) Two Bedroom
Are you considered Frail Elderly (see definition below): Yes ____ No____
To be considered Frail Elderly you must be a senior who is enrolled in Medicaid and need assistance with personal care/or community
living, such as shopping, laundry, medication management, nutrition, etc. Additional requirements apply. Contact us for more information.

Do you need a handicapped accessible unit? Yes No

Do you need a unit adapted for hearing or visual impairment? Yes No

Name of other person we can contact if you are not available:

Name Address Phone Number

INCOME/ASSET INFORMATION

Total Estimated Household Gross Annual Income $

Current Income: Applicant 1 Applicant 2

Gross Employment/month
Public Assistance
SSI/Social Security/month
IRA/Pension/month
Veterans Benefits
Unemployment
Alimony/Child Support
No Child Support
Self-Employment
Other Income

Are you or any adult member claiming zero income?

Bank Accounts:(include all household members)

Checking Account
Savings Account
Money Market Account
Credit Union
Other (please specify)

Present Assets:
Full value of stocks
Full value of bonds
Full value of CD's
Market value of Real Estate

Rev. 03/2021
Have you or any member of your household disposed of any assets for less then fair
market value with in the past 2 years? Yes No
If yes, please give dollar amount: $

EMPLOYMENT:
Applicant 1 Applicant 2
Name Name
Address Address
Phone Phone

Dates: From To Dates: From To

Type of Work Type of Work

PRESENT LIVING CONDITIONS:

Do You: □ own □ rent □ live with family or friend □ shelter or emergency housing

How long have you lived at your residence?

What is your rental cost each month?

Does your rent include utilities? Yes No

If No, what is your utility cost per month? (Do not include phone or cable) $

Do you receive rental assistance or rent subsidy? Yes No

If Yes, how much do you receive? $

Do you have a Section 8 voucher ? Yes No
If YES, is your rent paid in full by Section 8? Yes_______ No __________

How did you hear about this housing? □ Newspaper □ Internet □ Friend/Family □ Walk/Drive-By
□ Community Organization (name of company) ___________ □ Other (explain)________________

When would you be able to take an apartment?

Why do you wish to move?

Are you a Veteran?

Are you or any household members full time students?

Name (s)

Rev. 03/2021
In lieu of a credit check, can you provide 12 months history of on-time and in full rental payments?
Yes__________ No___________

REFERENCES:

REFERENCES ARE REQUIRED AS PART OF THE APPLICATION PROCESS. WE ASK YOU TO

LIST APPROPRIATE PERSONS WE MAY CONTACT AS REFERENCES.

LANDLORD REFERENCES - Please list all places of residence within the last five years

Present Landlord: (Use back of page for additional space).

Name
Address
Phone
Dates: From To
Previous Landlords:

Name Name
Address Address
Phone Phone
Dates: From To Dates: From To
Property Name Property Name
Previous Address Previous Address

PERSONAL REFERENCES (Not a relative):

Applicant 1 Applicant 2
Name Name
Address Address
Phone Phone

Name Name
Address Address
Phone Phone

PETS

How many pets do you have? Cats Dogs Other

List breed, weight and age of each pet:

Rev. 03/2021
 WE ARE AN EQUAL OPPORTUNITY HOUSING ORGANIZATION. WE WOULD APPRECIATE YOUR VOLUNTARY
ANSWER TO THE FOLLOWING QUESTIONS:

Ethnicity (Circle one)

Hispanic or Latino
Not Hispanic or Latino

Race (Circle all that apply)

American Indian, Alaska Native, Asian, Black or African American, Native Hawaiian, Pacific Islander,
or White.

******PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING******

WARNING! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS
GUILTY OF A FELONY FOR KNOWINGLY AND WILLFULLY MAKING FALSE OR FRAUDULENT
STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.
Any willful misrepresentation or concealment of any material fact that would affect eligibility for admission
will be considered grounds for termination of lease and eviction. I, therefore declare the information
provided to be true to the best of my knowledge.

Signature of Applicant #1 Signature of person assisting with application

Signature of Applicant #2 Name of person assisting with application

Date Address and Phone number

******PLEASE SIGN THE ATTACHED AUTHORIZATION FOR RELEASE OF INFORMATION******

Rev. 03/2021
 Authorization For Release of Information

I, (Applicant 1), (Applicant 2)

consent to allow SLM Apartments, LLC and PathStone Management Corporation to request and
obtain income, assets, credit, criminal, schooling, landlord and personal information from the sources
attached to this form for the purpose of verifying my eligibility and level of benefits under PathStone
Management Corporation housing programs. I understand that housing authorities that receive
income information under this consent form cannot use it to deny, refuse, or terminate assistance
without first independently verifying what the amount was, whether I actually had access to the funds
and when the funds were received. In addition, I must be given an opportunity to contest these
determinations.

I have read this document, and understand, and agree to the release of information in consideration
for my occupancy or continued occupancy of an apartment operated by SLM Apartments, LLC and
PathStone Management Corporation.

“In conjunction with our application or renewal of a lease, I hereby certify that all information contained
herein is true and correct. I understand that the material falsification of information provided may result in
the rejection of this application or in termination of my lease agreement.”

“By execution of this application, I hereby authorize SLM Apartments, LLC and PathStone
Management Corporation to make such investigation into my credit, employment, rental, and
criminal history per the tenant selection criteria, and release all parties from all liability for any damage
that may result from their furnishing information to you.”

Signatures:

Applicant 1
Name Date Social Security Number

Applicant 2
Name Date Social Security Number

Rev. 03/2021
 ANDREW M. CUOMO RUTHANNE VISNAUSKAS
Governor Commissioner/CEO

Know Your Rights: New York State’s Credit Policy for Applicants to State-Funded Housing
A housing provider/landlord cannot automatically deny your application to state-funded rental housing based solely on
your credit score or history. If you have a low credit score or negative credit history, you must be provided with
the opportunity to present additional information to explain or refute the findings.

What is the policy?

• You CAN avoid a credit check by evidencing that you paid your rent in full and on time during the last 12
months.
• You CANNOT be rejected because of your credit score or credit history if:
o Your FICO credit score is 580 or above (or 500 if you are homeless),
o You have limited or nonexistent credit history,
o Rent subsidies pay your entire rent,
o Your credit score or credit history is a direct result of a Violence Against Women Act (VAWA)-
covered crime (like domestic violence, stalking or harassment), or
o You have a history of bankruptcy or outstanding debt but present evidence of on-time rental payments
over the past 12 months.
• You CANNOT be rejected based on:
o Medical debt or student loan debt.
o Bankruptcies that occurred over 1 year ago.
o Unpaid debt that is less than $5,000.
o A past eviction or housing court history.
o Limited or no rent or credit history.
What are my rights?
• Housing providers must accept evidence that you paid your last 12 months rent in full and on time instead
of requiring a credit check.
• Housing providers may only reach out to your current or previous landlord without your permission to
obtain information on major lease violations.
• Housing providers are limited in the fees that they can charge you:
o A housing provider cannot charge you a credit or background check fee if you provide one to them that
was run within the last 30 days.
o A housing provider may not charge you more than $20 or the actual cost (whichever is less), to run
both a credit check and a background check.
• Before rejecting your application based on your credit report, you must be given 14 days to present
evidence of circumstances that explain negative credit findings such as such as errors in the credit report
and short-term periods of unemployment/illness.
• If you are denied, you must be told why and you must be provided with a copy of your credit report and
background check.
Find more information about your rights when applying to state-funded housing, including if you have a criminal

convictions, here: https://hcr.ny.gov/marketing-plans-policies#credit-and-criminal-convictions-assessment-policies

 ANDREW M. CUOMO RUTHANNE VISNAUSKAS
Governor Commissioner/CEO

Know Your Rights: New York State’s Anti-Discrimination Policy When Assessing
Justice-Involved Applicants for State-Funded Housing
If you are applying for state-funded housing and have a history of involvement with the criminal justice
system, you have rights and protections.

There Are Only Two Mandatory Reasons That You Can Automatically Be Rejected:
1. Conviction for methamphetamine production in the home; and
2. Being a lifetime registrant on a state or federal Sex Offender database.

You Cannot Be Rejected Based On:

1. Arrest records that were resolved in your favor;
2. Youthful offender adjudications;
3. Pending arrests with adjournments in contemplation of dismissal;
4. Convictions for violations sealed pursuant to Section 160.55 of New York State Criminal
Procedure Law;
5. Convictions sealed pursuant to Section 160.58 or 160.59 of New York State Criminal Procedure
Law;
6. Convictions that were excused by pardon, overturned on appeal or vacated;
7. Convictions or pending arrests that do not involve physical violence to persons or property, or
affected the health, safety and welfare of others

You Cannot Be Asked About 1-5 Above

If a housing provider asks you about such matters, you may answer as if the protected arrest, conviction
or adjudication never occurred. For more information on this protection, including how to file a complaint
if you believe you have been discriminated against, see the New York State Division of Human Right’s
Protections Under the Law for People with Arrest and Conviction Records (https://dhr.ny.gov/protections-
people-arrest-and-conviction-records).

You Must be Given 14 Days to Provide Additional Information Before Any Rejection
You must be contacted and provided 14 business days to provide additional relevant information including:
1. How much time has passed since the conviction(s)?
2. How old were you at the time of the conviction(s)?
3. How serious was the conviction(s)?
4. What evidence do you have about your rehabilitation, including treatment programs, volunteer
work, paid employment, etc. since your conviction(s)?

If you were not given an opportunity to answer these questions, or if you feel the housing provider did not
properly evaluate your application and wrongfully denied you housing, contact New York State Homes and
Community Renewal’s Fair and Equitable Housing Office at [email protected] for assistance. More
information is available here: https://hcr.ny.gov/marketing-plans-policies#credit-and-criminal-convictions-
assessment-policies
NYS HCR Fair and Equitable Housing Office (FEHO) - https://hcr.ny.gov/fair-housing
Form date: 03/02/2020
 Notice of Occupancy Rights under the Violence Against Women Act 1

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. 2 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 the rental housing or program, 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

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.

1
Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual
orientation.
2
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

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 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 Skyview Park Apartments (SLM

Apartments, LLC) and PathStone Management Corporation (acronym HP for purposes of this

document) 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 HP chooses to remove the abuser or perpetrator, HP 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, HP 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 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, HP must follow Federal, State, and

local eviction procedures. In order to divide a lease, HP may, but is not required to, ask you for

documentation or certification of the incidences of domestic violence, dating violence, sexual

assault, or stalking.
 3

Moving to Another Unit

Upon your request, HP 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, HP 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.

(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
 4

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.

HP 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.

HP’s emergency transfer plan provides further information on emergency transfers, and HP 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

HP 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 violence, sexual assault, or stalking. Such request

from HP must be in writing, and HP 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. HP 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 HP as documentation. It is your choice which of the

following to submit if HP 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 HP 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
 5

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

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 HP has agreed to accept.

If you fail or refuse to provide one of these documents within the 14 business days, HP does not

have to provide you with the protections contained in this notice.

If HP 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), HP has the right to request that you provide

third-party documentation within thirty 30 calendar days in order to resolve the conflict. If you
 6

fail or refuse to provide third-party documentation where there is conflicting evidence, HP does

not have to provide you with the protections contained in this notice.

Confidentiality

HP 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.

HP must not allow any individual administering assistance or other services on behalf of HP (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.

HP must not enter your information into any shared database or disclose your information to any

other entity or individual. HP, however, may disclose the information provided if:

• You give written permission to HP to release the information on a time limited basis.

• HP 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 HP or your landlord to release the information.

VAWA does not limit HP’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.

 7

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, HP cannot hold tenants who 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 HP 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 HP can demonstrate the above, HP 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.

For Additional Information

If you feel that they have been incorrectly denied your rights under VAWA, you should contact

NYS Homes and Community Renewal (HCR) at (518-474-9583).

 8

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).

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.

HCR has also created the HCR VAWA Local Services Provider List of local organizations,

including housing and legal service providers, that support individuals who are or have been

victims of domestic violence, available at

https://hcr.ny.gov/system/files/documents/2018/11/hcrvawaresourcelist.pdf

You may view a copy of HUD’s final VAWA rule at

https://www.federalregister.gov/documents/2016/12/06/2016-29213/violence-against-women-

reauthorization-act-of-2013-implementation-in-hud-housing-programs-correction.

Additionally, HP must make a copy of HUD’s VAWA regulations available to you if you ask to

see them.

Attachment: Certification form HUD-5382

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.

Form HUD-5382
(06/2017)
 2

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) ___________________________
______________________________________________________________________________________
_____________________________________________________________________________
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.

Form HUD-5382
(06/2017)