QUALIFIED THIRD PARTY VERIFICATION

Name of qualified third party:___________________   

                     
Name of tenant:_______________________                            

PART 1. STATEMENT BY TENANT

I,______________________(Name of tenant), do hereby state as follows:

(A) I or a minor member of my household have been a victim of domestic violence, sexual assault or stalking, as those terms are defined in ORS 90.100.

(B) The most recent incident(s) that I rely on in support of this statement occurred on the following date(s):
                        
    The time since the most recent incident took place is less than 90 days; or

     The time since the most recent incident took place is less than 90 days if periods when the perpetrator was incarcerated or was living more than 100 miles from my home are not counted. The perpetrator was incarcerated from_______to_______. The perpetrator lived more than 100 miles from my home from              to            
(C) I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury.

_________________________                   
(Signature of tenant)

Date:_________               

PART 2. STATEMENT BY QUALIFIED THIRD PARTY

I,__________________(Name of qualified third party), do hereby verify as follows:

(A) I am a law enforcement officer, attorney or licensed health professional or a victim’s advocate with a victims services provider, as defined in ORS 90.453.

(B) My name, business address and business telephone are as follows:

______________________

                       
______________________  

                         
______________________                           

(C) The person who signed the statement above has informed me that the person or a minor member of the person’s household is a victim of domestic violence, sexual assault or stalking, based on incidents that occurred on the dates listed above.

(D) I reasonably believe the statement of the person above that the person or a minor member of the person’s household is a victim of domestic violence, sexual assault or stalking, as those terms are defined in ORS 90.100. I understand that the person who made the statement may use this document as a basis for gaining a release from the rental agreement with the person’s landlord.

I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury.

_______________________                       
(Signature of qualified third party making this statement)