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VICTIM SERVICE PROVIDER CERTIFICATION <br />WNOMII:31IN <br />FOR EMERGENCY HOUSING VOUCHERS <br />Client Name: <br />Number of Adults in Household: <br />f O(7 IC1CI e <br />ENTRY SYSTEM <br />Date of Birth: <br />Number of Minor Children in Household: <br />This is to certify that the above named individual or household meets the definition for persons who are <br />fleeing, or attempting to flee, domestic violence, dating violence, sexual assault, stalking, or human <br />trafficking. <br />Name: <br />Title: <br />Signature: <br />Phone #: <br />Agency: <br />Date: <br />Confidentiality: All information provided concerning the incident(s) of domestic violence, dating violence, <br />sexual assault, stalking, or human trafficking shall be kept confidential and such details shall not be entered <br />into any shared database. This information must be protected and must not be disclosed to any other entity or <br />individual, except to the extent that disclosure is: (i) consented to by the applicant/tenant in writing in a time - <br />limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of assistance; <br />or (iii) otherwise required by applicable law. <br />City Council 31 — 32 7/20/202-1 <br />version 06/25/2021 <br />Page 25 of 29 <br />