I
verify under penalty of perjury under the laws of the state of Michigan 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 a reasonable apprehension of present danger
to the individual or his or her child from domestic violence, sexual assault,
or stalking, and that the individual informed me of the name of the alleged
perpetrator of the actions, giving rise to the apprehension 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 ... day of ...., 20...
..........................
Signature
of authorized
officer/employee
of
(organization,
agency,
clinic,
professional
service
provider)
..........................
License
number or organizational
tax
identification number
..........................
Organization
name
..........................
Printed
address
(4) The landlord shall reveal forwarding address information submitted by the tenant to other individuals only as reasonably necessary to accomplish the landlord's regular and ordinary business purpose. The landlord shall not intentionally reveal forwarding address information or documentation submitted by the tenant under this section to the person that the tenant has identified as the source of the reasonable apprehension of domestic violence, sexual assault, or stalking.
(5) If a rental agreement obligates multiple tenants to be liable for rental obligations and a tenant is released from his or her rental obligations under this section, all other tenants who are parties to the rental agreement remain subject to the rental agreement.