VICTIMS OF DOMESTIC VIOLENCE, DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING
OUR PURPOSE: Is to provide victims of domestic violence, dating violence, sexual assault, or stalking, and are seeking temporary emergency shelter assistance, you may use this form to request a temporary emergency shelter assistance and certify that you meet the requirements of eligibility for a temporary emergency shelter assistance under the Sherri Denese Jackson Foundation for the Prevention of Domestic Violence, Inc. Although the statutory name references women, The Violence Against Women Act (“VAWA”) rights and protections apply to all victims of domestic violence, dating violence, sexual assault or stalking. Using this form does not necessarily mean that you will receive and temporary emergency shelter assistance.
The requirements you must meet are: (1) You are a victim of domestic violence, dating violence, sexual assault, or stalking. If the domestic violence advocate does not already have documentation that you are a victim of domestic violence, dating violence, sexual assault, or stalking, your domestic violence advocate may ask you for such documentation. In response, you may submit other types of documentation requested. (Picture ID, Emergency Contact, and two References).
(2) You expressly request the temporary emergency shelter assistance. Submission of this form confirms that you have expressly requested a need for temporary emergency shelter assistance. Your domestic violence advocate may choose to require that you submit this form, or may accept another written or oral request.
(3) You reasonably believe you are threatened with imminent harm from further violence if you remain in your current situation. This means you have a reason to fear that if you do not receive temporary emergency shelter assistance you would suffer violence in the very near future.
OR You are a victim of sexual assault and the assault occurred in the home during the COVID-19 Pandemic period before you requested temporary emergency shelter assistance. If you are a victim of domestic violence, then in addition to qualifying for a temporary emergency shelter assistance because you reasonably believe you are threatened with imminent harm from further violence if you remain in your unit, you may qualify for a temporary emergency food and shelter assistance.
Submission of Documentation: If you have third-party documentation that demonstrates why you are eligible for a temporary emergency shelter assistance; you should submit that documentation to your domestic violence advocate provider if it is safe for you to do so. Examples of third party documentation include, but are not limited to: a letter or other documentation from a victim service provider, social worker, legal assistance provider, pastoral counselor, mental health provider, or other professional from whom you have sought assistance; a current restraining order; a recent court order or other court records; a law enforcement report or records; communication records from the perpetrator of the violence or family members or friends of the perpetrator of the violence, including emails, voicemails, text messages, and social media posts.
Confidentiality: All information provided to your domestic violence advocate concerning the incident(s) of domestic violence, dating violence, sexual assault, or stalking, and concerning your request for a temporary emergency shelter assistance shall be kept confidential. Such details shall not be entered into any shared database.
This is to certify that the information provided on this form is true and correct to the best of my knowledge and recollection, and that the individual named above has been a victim of domestic violence, dating violence, sexual assault, or stalking. I acknowledge that submission of false information could jeopardize program eligibility and could be the basis for denial of admission, termination of assistance.
This is to certify that the information provided on this form is true and correct to the best of my knowledge, and that the individual named above meets the requirement laid out on this form for a temporary emergency shelter assistance. I acknowledge that submission of false information could jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or eviction.
OUR LIABILITY STATEMENT
I, ________________________________________ understand, that if I am accepted to the COVID19 Temporary Shelter Program, I WILL NOT hold the Sherri Denese Jackson Foundation for the Prevention of Domestic Violence liable in any way. I understand that I am LEGALLY RESPONSONSIBLE for damages and incidentals. I also understand that the Sherri Denese Jackson Foundation will only pay for RECOMMEDED NIGHTS. I am aware that I will be charged for any additional nights THEREAFTER. For your SAFETY NO GUESTS UNLESS APPROVED BY THE SDJF FOUNDATION STAFF.
