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

_________________________________

1. 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

Name: ______ Date:______________________

Address:_______________________

______________________________

Dear Resident/Applicant:

You have indicated that you, or a member of your household, need a reasonable accommodation because of a disability in connection with a Public Housing Authority residence, facility, program or service. A physician, licensed health care professional, or a professional representing a social service agency or disability agency or clinic may verify this information.

Please take or mail this form, the attached Authorization for Release of Information and the enclosed stamped, pre-addressed envelope to your health care provider or other appropriate individual, clinic or agency. The Public Housing Authority will use this information to evaluate your request for a reasonable accommodation. The Public Housing Authority will keep this information confidential. If you choose not to authorize the release of this information, we may not be able to consider your reasonable accommodation request(s).

MODIFICATION/ACCOMMODATION REQUESTED:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

RE: Household member with disability: ________________________________________

I hereby authorize [Insert name of health care provider or other appropriate documenting authority] to release information and/or documentation to representatives of the Public Housing Authority concerning the physical or mental impairment(s) that I assert to qualify as a individual with a disability for the sole purpose of this reasonable accommodation request.

In addition, I authorize [Insert name of health care provider or other appropriate documenting authority] to provide only documentation that is necessary to verify that I meet the definition of a "Qualified Individual with a Disability", as defined above. This Authorization For Release of Information should only seek information that is necessary to determine if the requested reasonable accommodation is needed because of a disability.

This Authorization does not authorize the Public Housing Authority to examine my medical records, including diagnosis or test result(s); nor does this authorize the release of detailed information about the nature or severity of my disability. Any information or documentation released as a result of this Authorization shall be kept confidential and will not be shared with anyone unless required to make or assess a decision to grant or deny a reasonable accommodation request.

This Authorization solely authorizes the release of information necessary to verify the following:

1. Documentation necessary to verify that the above-named individual meets the definition of a "qualified individual with a disability", as defined below;

2. A description of the needed reasonable accommodation(s); and,

3. A description of the identifiable relationship between the individual’s disability and the requested reasonable accommodation(s).

For purposes of this Release, a "Qualified Individual With a Disability" is defined as a person who has a physical or mental impairment that:

1. Substantially limits one or more major life activitie
2. Has a record of such an impairment
3. Is regarded as having an impairment

"A Physical or Mental Impairment" is defined as:

1. Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems including, but not limited to: neurological, musculoskeletal, special sense organs, respiratory, and speech organs; or
2. Any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness and specific learning disabilities.

The term "Physical or Mental Impairment" includes, but is not limited to, such diseases and conditions as visual, speech and hearing impairments, epilepsy, multiple sclerosis, cancer, etc.

"Major Life Activities" include functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

"Has a Record of Such an Impairment (mental or physical)" means has a history of, or has been misclassified as having, a mental or physical impairment that substantially limits one or more major life activities.

"Is Regarded As Having an Impairment" means:

1. Has a physical or mental impairment that does not substantially limit one or more major life activities, but is treated by a recipient as constituting such a limitation.

2. Has a physical or mental impairment that substantially limits one or more major life activities only as a result of the attitudes of others toward the impairment.

3. Has none of the impairments defined by Section 504’s definition of "physical or mental impairment, but is treated by a recipient as having such an impairment.

I hereby authorize the release of information to the Public Housing Authority regarding the request for reasonable accommodation described on this form. This release shall constitute a limited authorization for the release of information, as described above.

__________________________________________

Name of Family Member/Parent/Legal Guardian [Print]

_____________________________________________

Signature

_____________________________________________

Relationship to Applicant/Resident

_____________________________________________

Date

PLEASE PROVIDE THE FOLLOWING INFORMATION:

1. Name of Health Care Provider/Documenting Authority:

____________________________________________

2. Address of Health Care Provider/Documenting Authority:

_____________________________________________

_____________________________________________

_____________________________________________

3. Telephone Number of Health Care Provider/Documenting Authority:

_____________________________________________

(4) Facsimile Number of Health Care Provider/Documenting Authority:

_____________________________________________

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.

Date:________________________

To: [Provide Applicant/Resident’s Name & Address]

Dear Applicant or Resident:

We have received and approved your request for reasonable accommodation. Specifically, you requested [describe specific accommodation request(s)].

• _____We will provide you with the requested accommodation(s) by [date].

• _____Although we have approved your request, we will not be able to complete your accommodations until [date]
• due to [describe the reason(s) for the delay.]

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

If you have any questions regarding this matter, please contact this office [provide contact information]. If you think that this change or modification is not what you requested; if this is unacceptable; or, if you object to the length of time it will take to provide your request, you may contact the Public Housing Authority

 Section 504/Coordinator at [provide name, address, telephone number of Section 504/ADA Coordinator.]

In addition, you may exercise your right to appeal a PHA decision through your local HUD office or the U.S. Department of Justice. You may contact the local HUD office at:

U.S. Department of Housing and Urban Development

HUB Office

Address

City/State/Zip Code

Telephone: ( )

Facsimile: ( )

TDD/TTY Number:

Sincerely,

Name/Title

Public Housing Authority

Date:________________________

To: [Provide Applicant/Resident’s Name & Address]

Dear Applicant or Resident:

We have received your request for reasonable accommodation. Specifically, you requested [describe specific accommodation request(s)]. Following our review of your request, we have denied your request for the following reason(s):

_____You do not meet the definition of a "qualified individual with a disability" as explained in the "Reasonable

Accommodation Policy" and, therefore, we are not required to provide you with a reasonable accommodation.

_____We have determined that your request is not "reasonable" for the following reasons: [describe specific basis

for unreasonable determination]__________ _______________________________________________________________

______________________________________________________________________________________________________

______________________________

_____Your requested accommodation is structurally infeasible for the following reasons: [describe reasons for structural infeasibility determination.]_______________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____Your requested accommodation would result in a fundamental alteration in the nature of our program for the

following reasons: [describe reasons for fundamental alteration determination.]________________________________

______________________________________________________________________________________________________

________________________________________________________________________________________________

_____Your requested accommodation would result in an undue financial and administrative burden for the PHA

for the following reasons: [describe reasons for undue financial and administrative burden determination.]_____ __________________________________________________________________ ______________________________________________________________________________________________________

________________________________________________________________________________________________

_____ Although we were unable to approve your specific reasonable accommodation request(s) for the foregoing reason(s), we would like to meet with you to discuss an equally effective accommodation that may meet your needs, we would like to propose the following alternate, reasonable accommodation: [describe alternate, proposed reasonable accommodation(s)]_________________________________________________________________________________________________________

__________________________________________________________________________

If you would like to discuss the alternate, proposed accommodation(s), we would like to meet with you to discuss an equally effective accommodation that may meet your needs. You may bring a friend, advocate or attorney with you to meet with us. We would like to meet with you on [insert date, time and location, including address, of proposed meeting.] If you are unable to meet with us at this scheduled time, please contact our office at [provide office telephone number] to reschedule a mutually convenient date and time for the meeting. If you disagree with our decision, you may contact Public Housing Authority Section 504/Coordinator at [provide name,

address, telephone number of Section 504/ADA Coordinator.]

In addition, you may exercise your right to appeal a PHA decision through your local HUD office or the U.S. Department

of Justice. You may contact the local HUD office at:

U.S. Department of Housing and Urban Development

HUB Office

Address

City/State/Zip Code

Telephone: ( )

Facsimile: ( )

TDD/TTY Number:

Sincerely,

Name/Title

Public Housing Authority