This form is used for collecting data from a family member, spouse or roommate of an individual who was listed on their lease and, either:

1. Was arrested while residing in their house hold.
2. A domestic violence incident occurred, resulting in an arrest.

As a direct result the Housing Assistance, recipient's (low income, subsidized, public or section 8 housing) certificate was terminated.  

The data will be used to create a report that will document how the current housing policies discriminate and target a particular population as well as adding to the increasing homeless problem in the Commonwealth of Massachusetts.