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Page 1 of 6 PUBLIC HOUSING AUTHORITY (Example) REQUEST FOR REASONABLE ACCOMMODATION Note: Access-Andrews Consulting can modify this form and others in this section to fit any housing situation, whether public or private or a combination of Federal and other funded properties. |
You may utilize this form to request that the Public Housing Authority (PHA) provide a reasonable accommodation to you, or any member of your household who has a disability, so that you or a member of your household may utilize your residence, or any of the PHA’s facilities, programs or services. For purposes of this form, please refer to the attached "Reasonable Accommodation Policy" to determine whether you are a "qualified individual with a disability". If you would like to request a reasonable accommodation on behalf of yourself or a member of your household, please complete this form. You must date and sign your name at the bottom of this form and return the form to the property manager’s office. If you need assistance in understanding whether you or a member of your household is a "qualified individual with a disability" or if you need assistance in completing this form, please contact your local property management office or the PHA’s Section 504/ADA Coordinator. _________________________________ _____________________________ Date of Request Social Security Number _________________________________ _____________________________ Name of Applicant/Resident/Participant Telephone Number _________________________________ ______________________________ Address City/State/Zip Code _________________________________ - I am requesting the following reasonable acommodation(s):____________________
_________________________________________________________________________ _________________________________________________________________________ 2. I am requesting the reasonable accommodation(s) on behalf of: (name): _________________________________________________________________________ 3. My reason(s) for requesting this reasonable accommodation: __________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 4. A physician, licensed health care professional, professional representing a social service agency, disability agency or clinic may provide verification of your disability. You may request a physical modification to your current unit or a transfer to a unit that has been previously modified [in your development or another development]. The Public Housing Authority will work with you to determine how to fulfill your reasonable accommodation request. The Public Housing Authority may require documentation to support your reasonable accommodation request(s). Please indicate which option you prefer: ___ I wish to have modifications made to my current unit only ___ I would consider moving to a unit that is currently modified, but only within my current development ___ I would consider moving to a unit that is currently modified, even in another development ___________________________________ _____________________________ Signature of Applicant/Resident/Participant Date
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