Cal. Code Civ. Proc. § 1161.3
Tenant Statement and Qualified Third Party Statement under Code of Civil Procedure Section 1161.3 | |
Part I.Statement By Tenant | |
I, [insert name of tenant], state as follows: | |
I, my immediate family member, or a member of my household, have been a victim of: | |
[insert one or more of the following: domestic violence, sexual assault, stalking, human trafficking, elder abuse, dependent adult abuse, a crime that caused bodily injury or death, a crime that included the exhibition, drawing, brandishing, or use of a firearm or other deadly weapon or instrument, or a crime that included the use or threat of force against the victim.] | |
The most recent incident(s) happened on or about: | |
[insert date or dates.] | |
The incident(s) was/were committed by the following person(s), with these physical description(s), if known and safe to provide: | |
[if known and safe to provide, insert name(s) and physical description(s).] | |
(signature of tenant)(date) | |
Part II.Qualified Third Party Statement | |
I, [insert name of qualified third party], state as follows: | |
My business address and phone number are: | |
[insert business address and phone number.] | |
Check and complete one of the following: | |
____I meet the requirements for a sexual assault counselor provided in Section 1035.2 of the Evidence Code and I am either engaged in an office, hospital, institution, or center commonly known as a rape crisis center described in that section or employed by an organization providing the programs specified in Section 13835.2 of the Penal Code. | |
____I meet the requirements for a domestic violence counselor provided in Section 1037.1 of the Evidence Code and I am employed, whether financially compensated or not, by a domestic violence victim service organization, as defined in that section. | |
____I meet the requirements for a human trafficking caseworker provided in Section 1038.2 of the Evidence Code and I am employed, whether financially compensated or not, by an organization that provides programs specified in Section 18294 of the Welfare and Institutions Code or in Section 13835.2 of the Penal Code. ____I meet the definition of "victim of violent crime advocate" provided in Section 1946.7 of the Civil Code and I am employed, whether financially compensated or not, by an agency or organization that has a documented record of providing services to victims of violent crime or provides those services under the auspices or supervision of a court or a law enforcement or prosecution agency. | |
____I am licensed by the State of California as a: | |
[insert one of the following: physician and surgeon, osteopathic physician and surgeon, registered nurse, psychiatrist, psychologist, licensed clinical social worker, licensed marriage and family therapist, or licensed professional clinical counselor.] and I am licensed by, and my license number is: | |
[insert name of state licensing entity and license number.] | |
The person who signed the Statement By Tenant above stated to me that they, a member of their immediate family, or a member of their household is a victim of: | |
[insert one or more of the following: domestic violence, sexual assault, stalking, human trafficking, elder abuse, dependent adult abuse, a crime that caused bodily injury or death, a crime that included the exhibition, drawing, brandishing, or use of a firearm or other deadly weapon or instrument, or a crime that included the use or threat of force against the victim.] | |
The person further stated to me the incident(s) occurred on or about the date(s) stated above. | |
(signature of qualified third party)(date) | |
Ca. Civ. Proc. Code § 1161.3