WA State Department of Commerce 9/25/2017

Acknowledgement of Notice of Statutory Requirement to Comply with the Confidentiality and Privacy Provisions of the Violence Against Women Act, as Amended (Victim Services Providers Only) Applicant Agency Name City of Everett NOTE: If the applicant is a criminal justice agency with a community-based victim service provider receiving STOP Grant funds in their grant,the victim services provider must complete this form to be submitted by the criminal justice applicant. Under section 40002(b)(2) of the Violence Against Women Act, as amended (42 U.S.C. 13925(b)(2)), grantees and subgrantees with funding from the Office on Violence Against Women are required to meet the following terms with regard to nondisclosure of confidential or private information and to document their compliance. By signature on this form, applicant for the STOP Grant acknowledges that that they have notice that, if awarded funds,they will be required to comply with this provision, and will mandate that subgrantees, if any, comply with this provision, and will create and maintain documentation of compliance,such as policies and procedures for release of victim information, and will mandate that subgrantees, if any, will do so as well. (A) In general In order to ensure the safety of adult,youth, and child victims of domestic violence, dating violence,sexual assault,or stalking, and their families,grantees and subgrantees under this subchapter shall protect the confidentiality and privacy of persons receiving services. (B) Nondisclosure Subject to subparagraphs (C) and (D), grantees and subgrantees shall not-- (i)disclose, reveal,or release any personally identifying information or individual information collected in connection with services requested, utilized, or denied through grantees' and subgrantees' programs, regardless of whether the information has been encoded, encrypted, hashed, or otherwise protected;or (ii) disclose, reveal, or release individual client information without the informed,written, reasonably time- limited consent of the person (or in the case of an unemancipated minor,the minor and the parent or guardian or in the case of legal incapacity,a court-appointed guardian) about whom information is sought,whether for this program or any other Federal,State,or Tribal grant program, except that consent for release may not be given by the abuser of the minor, incapacitated person, or the abuser of the other parent of the minor. If a minor or a person with a legally appointed guardian is permitted by law to receive services without the parent's or guardian's consent,the minor or person with a guardian may release information without additional consent. (C) Release If release of information described in subparagraph (B) is compelled by statutory or court mandate-- (i)grantees and subgrantees shall make reasonable attempts to provide notice to victims affected by the disclosure of information;and (ii)grantees and subgrantees shall take steps necessary to protect the privacy and safety of the persons affected by the release of the information.