Dakota County CDA New Admissions Informal Review Request Form (Housing Choice Voucher Program) and HUD Form 5382, Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and Alternate Documentation Completed Form Examples and Samples
View completed samples of the Dakota County CDA New Admissions Informal Review Request Form and HUD Form 5382. Learn how to fill out the Certification of Domestic Violence (VAWA) and properly request an informal review for the Housing Choice Voucher Program with our detailed examples.
Dakota County CDA Informal Review & HUD-5382 VAWA Certification Example
How this form was filled:
This example shows how an applicant, denied admission to the Housing Choice Voucher program due to a criminal record stemming from a domestic violence incident, requests an informal review. The applicant correctly fills out the Dakota County CDA form and attaches the HUD-5382 to certify their status as a victim under the Violence Against Women Act (VAWA).
Information used to fill out the document:
- Applicant's Name: Jane A. Smith
- Applicant's Address: 123 Elm Street, Apt 4B, Eagan, MN 55121
- Applicant's Phone: (651) 555-0101
- Applicant's Email: [email protected]
- Date of Denial Letter: March 10, 2026
- Reason for Denial Cited: Criminal activity by a household member
- Reason for Review Request: The criminal activity cited was a direct result of me being a victim of domestic violence. I am submitting HUD Form 5382 as evidence under VAWA. The incident occurred over five years ago and should not be the basis for my denial.
- Date of Review Request: March 20, 2026
- Associated Form: HUD Form 5382
- Name of Perpetrator (on HUD-5382): John Doe
- Date of Domestic Violence Incident: October 5, 2020
- Certification: Applicant certifies she is a victim of domestic violence.
- Signature: Jane A. Smith
What this filled form sample shows:
- A clear, concise statement explaining why the denial should be overturned, referencing VAWA protections.
- Correct completion of the applicant's personal information and the date of the denial notice.
- Submission of HUD Form 5382 as supporting documentation to self-certify as a victim of domestic violence.
- The request is dated and signed, ensuring it is submitted in a timely manner according to program rules.
Form specifications and details:
| Form Name 1: | Dakota County CDA New Admissions Informal Review Request Form (Housing Choice Voucher Program) |
| Form Name 2: | HUD Form 5382, Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and Alternate Documentation |
| Use Case: | Appealing a Housing Choice Voucher program denial based on VAWA protections for victims of domestic violence. |
| Jurisdiction: | Dakota County, Minnesota |
Created: February 03, 2026 07:20 PM
