Receipt of Lead-Based Paint Notification
Applicant/Program Participant Name:
VAWA was reauthorized in 2013, and provides basic protections and rights for applicants and residents receiving rental assistance. The “Notice of Occupancy Rights under the Violence Against Women Act” based on HUD form 5380, and the “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking,” HUD form 5382, must be provided to applicantsof and Program Participants in the ESG Program.
Initial Receipt of “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking” at submission of Application for rental assistanceI have received, read, and understand the “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking” (HUD Form 5382).
Applicant Signature / Date of Application
Receipt of “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking”Prior to Execution of a Rental Assistance Agreementwith ESG Subrecipient
I have been approved to receive ESG rental assistance and I have received, read, and understand the “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking” (HUD Form 5382).
Participant Signature / Date of Rental Assistance Agreement
Receipt of “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking”at notification of Eviction or Termination of Assistance
I am being evicted or my ESG rental assistance is terminating and I have received, read, and understand the “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking” (HUD Form 5382).
Participant Signature / Date of Eviction/Non Renewal of Lease
Receipt of “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking”at Annual Recertification of ESG certification or upon lease renewal
I am renewing my ESG rental assistance, or my lease is being renewed, and I have received, read, and understand the “Notice of Occupancy Rights under the Violence Against Women Act” and “Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking” (HUD Form 5382).
Participant Signature / Date of Lease Renewal
Reasonable accommodations will be made for persons with disabilities and language assistance will be made available for persons with limited English proficiency.
/ Texas Department of Housing and Community Affairs
Street Address: 221 East 11th Street, Austin, TX 78701 Mailing Address: PO Box 13941, Austin, TX 78711
Main Number: 512-475-3800 Toll Free: 1-800-525-0657 Email: Web: /
TDHCA ESG Program Page 1 of 1
Receipt of VAWA Rights and Protections June 2017