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 Instructions

Enter the name of the accused perpetrator, if known and safe to disclose (first line).

Describe how the accused perpetrator is related to the victim (for example, spouse, partner, family member, roommate, or other relationship).

Enter any remaining portion of the accused perpetrator's name that did not fit on the first line.

Enter any notes or additional information to be included with the Attachment (Certification form HUD-5382).

Enter the date on which the certification was signed.

Enter the signature of the person certifying that the information provided on the form is true and correct.

Describe the disqualifying criminal or drug-related activity in detail, including dates, locations, persons involved, charges or allegations, case numbers, outcomes (conviction, dismissal, probation, treatment), and note any supporting documents you are attaching. Fill only if 'Criminal or Drug Activity' is 'Yes'.

Check this box if the informal review is about disqualifying criminal or drug-related activity (for example arrests, charges, convictions, probation violations, or drug possession/use) that affects the household’s eligibility.

Check this box if a household member is currently engaged in, or has engaged in, violent criminal activity as defined by HUD (involving use, attempted use, or threatened use of physical force substantial enough to cause or likely to cause serious bodily injury or property damage).

Check this box if a household member has engaged in criminal activity that may threaten the health or safety of property owners, management staff, or persons performing contract or administrative functions for the CDA (including employees, contractors, subcontractors, or agents).

Check this box if a household member has a pattern of criminal activity over the most recent 10 years that may threaten the health, safety, or peaceful enjoyment of the premises by other residents or persons within a half‑mile radius, or that may cause damage to property.

Provide a clear, detailed explanation of the alleged fraudulent activity, including dates, persons involved, and any relevant circumstances or events. Fill only if 'Fraudulent Activity' is 'Yes'.

List or briefly describe any supporting documents you are attaching for the fraud claim (for example police reports, correspondence, receipts, or court documents) or indicate which documents are included. Fill only if 'Fraudulent Activity' is 'Yes'.

Check this box if the application or admission was denied, terminated, or otherwise affected because of alleged or confirmed fraud; attach any supporting documents you want the CDA to consider in their review.

Enter the head of household's Social Security Number.

Enter the head of household's primary work or cell phone number.

Enter the ZIP code for the household address.

Enter the head of household's home phone number.

Enter the state for the household address (use the standard two-letter abbreviation if applicable).

Enter the city for the household address.

Enter the household street address, including apartment or unit number if applicable.

Enter the full name of the head of household.

Enter the full name of the housing provider (HP) responsible for issuing this notice.

Provide any additional date and time details for the incident(s) that did not fit in the first line.

Enter the date(s) and time(s) when the incident(s) occurred, if known.

Enter the location(s) where the incident(s) took place.

Enter the next line of your brief description of the incident(s) in your own words.

Provide the main narrative describing what happened during the incident(s), including relevant details.

Enter the first line of your brief description of the incident(s) in your own words.

Enter any and all information you want the CDA to consider for your informal review (for example: explanation of events, names, dates, addresses, reasons why the decision is incorrect, and references to any supporting documents you are submitting).

Explain, in your own words, why you withheld information from the CDA that led to the misrepresentation denial. Fill only if 'Misrepresentation' is 'Yes'.

Provide details about the alleged misrepresentation and list or summarize any supporting evidence or documents you are attaching for the review. Fill only if 'Misrepresentation' is 'Yes'.

Check this box if the denial was due to misrepresentation (you withheld or provided false information) and you are requesting an informal review on that basis.

Enter a detailed explanation of the other disqualifying reason being appealed, including dates, names, circumstances, and any facts you want the reviewer to consider. Fill only if 'Other' is 'Yes'.

List or briefly describe any supporting documents you are attaching (for example police reports, court documents, treatment records) or note what additional evidence is available for the reviewer. Fill only if 'Other' is 'Yes'.

Check this box if the applicant was denied for a disqualifying reason not listed above (an “Other” reason) and attach any supporting documents you want the CDA to consider.

Enter the requested information or additional notes for this unlabeled large text area. Fill only if 'Misrepresentation' is 'Yes'.

Enter the date the victim received the written request.

Enter the full name of the victim.

Enter the name(s) of any other family member(s) listed on the lease.

Enter your full name if you are completing this form on behalf of the victim and your name is different from the victim’s. Fill only if 'Victim Name' is different (all).

Enter the victim’s residence address.

Enter additional name(s) of other family member(s) listed on the lease if more space is needed.