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Page 4 of 6 PUBLIC HOUSING AUTHORITY REQUEST FOR REIMBURSEMENT |
Remember to attach a completed "Request for Reasonable Accommodation" to this Request for Reimbursement To Resident: You should use this form if you made changes, at your expense, to your dwelling unit to accommodate the needs of a household member with a disability. You may be entitled to reimbursement for the expenses you incurred as a result of the modifications. Please complete this form to report all changes you made to your unit, including the costs of those changes. Please also attach copies of any receipts or other verification of the changes you made to your unit and the expenses you incurred. You must also complete and attach the "Request for a Reasonable Accommodation" in order to document that you or a household member is a qualified individual with a disability and needed the changes to the unit as a result of the disability. Name of Resident Seeking Reimbursement:________________________________________ Please Print Property Name:_______________________________________________________________ Address:_____________________________________________________________________ Name of Household Member with a Disability:_______________________________________ Please list all reasonable accommodation changes you made to your unit:__________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Please list all costs you incurred for each change you made to your unit: [Please attach all receipts or other verifications.]____________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Please remember that only modifications that you made as a result of the needs of you or a member of your household with a disability will be considered for reimbursement. Thank you.
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