Housing Laws

If you do not have a sexual assault protective order, a qualified third party must sign a certification of sexual assault, which should be “substantially the same” as this form provided in the statute¹:

(Name of qualified third party and, if applicable, the name of their sexual assault center, office, or agency)

I have suffered sexual assault as defined in La. R.S. 9:3261.2.

Briefly describe the incident giving rise to the claim of sexual assault: [Fill in details of the sexual assault here]

The incident(s) that I rely on in support of this declaration occurred on the following date(s) and time(s): ________ and at the following location(s): ________.

The incident(s) that I rely on in support of this declaration was/were committed by the following person(s), if known: ________.

I state under penalty of perjury under the laws of the state of Louisiana that the foregoing is true and correct. By submitting this statement I do not waive any legally recognized privilege protecting any communications that I may have with the agency or representative whose name appears below or with any other person or entity. I understand that my obligation to pay rent does not end until the early termination date of my lease as decided by the lessor or until I vacate the premises upon receiving agreement by the lessor to terminate my obligations under the lease early. I understand that my lessor may keep my security deposit or other amounts as permitted under law.

Dated at __________, Louisiana, __________ this day of ___ 20___.

(Signature of Tenant (Lessee))

PRINTED NAME [Your name goes here]

I verify under penalty of perjury under the laws of the state of Louisiana that I have provided services to the person whose signature appears above and that, based on information communicated to me by the person whose signature appears above, the individual has suffered sexual assault as defined by La. R.S. 9:3261.2, and that the individual informed me of the name of the alleged perpetrator of the actions (if known), giving rise to the claim, if known. This verification does not waive any legally recognized privilege that I, my agency, or any of its representatives have with the person whose signature appears above.

Dated this ________ of __________, 20___.

(Signature of qualified third party)

PRINTED NAME [The qualified third party’s name goes here]

(License number or organizational tax identification number)

(Organization name)

(Printed address)

¹ La. Rev. Stat. § 9:3261.2(D)