(D) Provides a signed self-certification form provided by the circuit court. The circuit court shall develop and provide forms for self-certification modeled after those developed by the New Hampshire housing finance authority in accordance with the Violence Against Women Act, 24 CFR section 5.2007(b)(1)(i). The self-certification form developed by the circuit court shall include the same information as is required by 24 CFR section 5.2005(a)(1)(ii); and
(i) Language swearing that the facts provided by the tenant in the self-certification form are true and accurate to the best of their knowledge and recollection; and
(ii) Language informing the tenant that false statements may be subject to criminal penalties, including potentially perjury.
II. The written verification provided to the lessor or owner, including the fact that an individual is a victim of domestic violence, sexual assault, or stalking, shall be maintained in strict confidence. The lessor or owner shall not disclose this information to any other entity or individual, except to the extent that disclosure is:
(a) Requested or consented to in writing by the tenant or household member of the tenant who is the victim of domestic violence, sexual assault, or stalking;
(b) Relevant and reasonably necessary for use in an eviction proceeding or hearing regarding termination of housing assistance; or
(c) Otherwise required by applicable law.
III. The tenant who has given notice pursuant to paragraph I shall vacate the premises within 30 days of giving notice to the landlord or at any other time as may be agreed upon by the landlord and the tenant.