Briefly describe the incident giving rise to the reasonable
apprehension of domestic violence, sexual assault, or stalking: ......................................................................................................................................
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 Michigan 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 will
end no later than the first day of the second month that rent is due after I
give notice. My obligation to pay rent does not end until I vacate the
premises. I understand that my landlord may keep prepaid amounts, including
first and last months' rent and all or part of my security deposit or other
amounts as allowed under law.
Dated
at ..... (city) ..., Michigan, this ... day of ...., 20...
..........................
Signature
of Tenant or
Household
Member