RHIIP Listserv #373 - Model forms for VAWA available on

HUD has created Microsoft Word files for the four model forms included in the Violence Against Women Act (VAWA) final rule that was published in the Federal Register on November 16, 2016.

These forms are now available on the Office of Multifamily Housing's web page.  The forms are as follows: 
  • VAWA Appendix A: Notice of Occupancy Rights Under the Violence Against Women Act, form HUD-5380
  • VAWA Appendix B: Model Emergency Transfer Plan for Victims of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, form HUD-5381
  • VAWA Appendix C: Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking and Alternate Documentation, form HUD-5382and 
  • VAWA Appendix D: Emergency Transfer Request for Certain Victims of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, form HUD-5383
Please note:
  • These Departmental forms are model forms and owners/agents can customize them for their company and properties, as long as they contain the same information and language.
  • During the 12-month period following the effective date of the VAWA regulation, owners/agents must give each household the notice of occupancy rights and the certification form either during the annual recertification or lease renewal process, or, if there will be no recertification or lease renewal for a household during the first year after the rule takes effect, through other means.  The 12-month period is December 16, 2016 through December 15, 2017.
  • Beginning on December 16, 2017, owners/agents must provide the Notification of Occupancy Rights and Certification forms to applicants when assistance is being denied or at the time the new household moves into the property.  The forms do not have to be provided to every applicant on a property's waiting list.
  • The Office of Multifamily Housing will be updating our current VAWA certification form, HUD-91066.  In the meantime, owners/agents should use the Departmental form.
  • Owners/agents are required to develop and implement an Emergency Transfer Plan by June 14, 2017, and should use the Departmental Emergency Transfer Plan form as a guide.
  • Owners/agents may require tenants seeking an emergency transfer to provide a written  Emergency transfer request.  To facilitate this, owners/agents can provide the Departmental Request form to their tenants. 
  • At this time the Office of Multifamily Housing does not plan to create our own Emergency Transfer Plan and Emergency Transfer Request forms, so owners/agents should use the Departmental forms.
  • Multifamily Housing will be updating our Lease Addendum form, HUD-91067 in the coming months.  In the meantime, owners/agents may continue to use this form.
    • We will have further written guidance available early next year and will plan to include a sample lease addendum that can be used prior to the update of form 91067.
For your reference, please see the attached RHIIP announcement sent on November 18, 2016, about the Violence Against Women Reauthorization Act of 2013 (VAWA) Final Rule.

You can view the RHIIP Tips Archives, under "Listserv-Multifamily RHIIP Tips" at



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