"(Name of qualified third party and, if applicable, the name of their sexual assault center, office, or agency)
I have suffered sexual assault as defined in R.S. 9:3261.2.
Briefly describe the incident giving rise to the claim of sexual assault:
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 the penalties provided in R.S. 14:125 that the foregoing is true and correct. By submitting this statement, I do not waive any legally recognized privilege protecting any communications that I 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 does not end until the early termination date of my lease as decided by the lessor or until I vacate the premises upon receiving agreement by the lessor to terminate my obligations under the lease early.
Dated at ____________, Louisiana, this ______ day of ____ 20 ___.
Signature of Lessee
I verify under the penalties provided in R.S. 14:125 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 suffered sexual assault as defined by R.S. 9:3261.2, and that the individual informed me of the name of the alleged perpetrator of the actions (if known), giving rise to the claim, 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 qualified third party)
PRINTED NAME
(License number or organizational tax identification number)
(Organization name)
(Printed address)"
La. R.S. § 9:3261.2