"Victim Leave Affidavit Form" - Colorado

Victim Leave Affidavit Form is a legal document that was released by the Colorado Department of Military and Veterans Affairs - a government authority operating within Colorado.

Form Details:

  • Released on December 8, 2003;
  • The latest edition currently provided by the Colorado Department of Military and Veterans Affairs;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Military and Veterans Affairs.

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Download "Victim Leave Affidavit Form" - Colorado

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STATE OF COLORADO
VICTIM LEAVE AFFIDAVIT
This form may be used for documenting the existence of valid reasons for use of the state provided victim protection leave.
Date:______________________
Employee’s Name:_________________________
Agency Name:
_________________________
I, the undersigned, attest to the following facts:
1. I have been the victim of domestic abuse as defined by C.R.S. 13-14-101(2), the victim of
stalking as defined by CRS 18-9-111(4), the victim of sexual assault as defined by CRS 18-3-
402, or the victim of another crime where the underlying factual basis has been found by a court
to include an act of domestic violence as defined in CRS 18-6-800.3(1).
2. I have used leave from work to protect myself or my children by:
a. making my home secure from the perpetrator;
b. seeking new housing to escape the perpetrator;
c. seeking legal assistance to address issues arising from the act or crime; or
d. preparing for court-related proceedings arising from the act or crime.
I certify that the information contained herein is true and complete to the best of my knowledge. I
understand that fraudulent certification of my reason for needing leave may result in the denial of the
leave and any other action deemed appropriate.
__________________________________________________
______________________
SIGNATURE
DATE
Employee ID Number:______________________________
affidav 12/8/03
STATE OF COLORADO
VICTIM LEAVE AFFIDAVIT
This form may be used for documenting the existence of valid reasons for use of the state provided victim protection leave.
Date:______________________
Employee’s Name:_________________________
Agency Name:
_________________________
I, the undersigned, attest to the following facts:
1. I have been the victim of domestic abuse as defined by C.R.S. 13-14-101(2), the victim of
stalking as defined by CRS 18-9-111(4), the victim of sexual assault as defined by CRS 18-3-
402, or the victim of another crime where the underlying factual basis has been found by a court
to include an act of domestic violence as defined in CRS 18-6-800.3(1).
2. I have used leave from work to protect myself or my children by:
a. making my home secure from the perpetrator;
b. seeking new housing to escape the perpetrator;
c. seeking legal assistance to address issues arising from the act or crime; or
d. preparing for court-related proceedings arising from the act or crime.
I certify that the information contained herein is true and complete to the best of my knowledge. I
understand that fraudulent certification of my reason for needing leave may result in the denial of the
leave and any other action deemed appropriate.
__________________________________________________
______________________
SIGNATURE
DATE
Employee ID Number:______________________________
affidav 12/8/03