Certification of Domestic Violence View the Notice of Occupancy Rights under the Violence Against Women Act Date the written request is received by the victim: MM slash DD slash YYYY Name of victim: Your name (if different from victim's): Name(s) of other family member(s) listed on the lease: Residence of victim: Name of the accused perpetrator (if known and can be safely disclosed): Relationship of the accused perpetrator to the victim: Date(s) and times(s) of incident(s) if known: Location of incident(s): In your own words, briefly describe the incident(s):Signature(Required) Reset signature Signature locked. Reset to sign again Signed on Date(Required) MM slash DD slash YYYY