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Get Reasonable Accommodation Form Template

Household member fills-in pink areas. For Accessible Units Reasonable Accommodations and Structural Modifications DATE TO Verification Source s Name ADDRESS FROM Housing Specialist SUBJECT Disability Verify Need for Reasonable Accommodation HOUSEHOLD MEMBER S NAME The household member named above has applied for or is receiving federal rental assistance at our site. The household member has requested an accessible unit accommodation or modification to their unit. We are required to verify that the household member qualifies as disabled under federal law and requires what he or she has requested. We would appreciate your cooperation in answering the questions on this form and returning it to the Housing Specialist listed above. FORT COLLINS HOUSING AUTHORITY Reasonable Accommodation Verification Doctor / Verification Source fills-in yellow areas. Household member fills-in pink areas. For Accessible Units Reasonable Accommodations and Structural Modifications DATE TO Verification Source s Name ADDRESS FROM Housing Specialist SUBJECT Disability Verify Need for Reasonable Accommodation HOUSEHOLD MEMBER S NAME The household member named above has applied for or is receiving federal rental assistance at our site. The household member has requested an accessible unit accommodation or modification to their unit. We are required to verify that the household member qualifies as disabled under federal law and requires what he or she has requested* We would appreciate your cooperation in answering the questions on this form and returning it to the Housing Specialist listed above. --------------------------------------------------------------------------------------------------------------------- YOU DO NOT HAVE TO SIGN THIS FORM IF THE NAME OR ADDRESS OF EITHER THE HOUSING COORDINATOR OR THE VERIFICATION SOURCE IS LEFT BLANK. RELEASE I hereby authorize the release of the requested information* Signature Date 1 of 2 Updated 03/15/2011 /cg INFORMATION REQUESTED 1. Is the household member disabled as defined below Yes No Under federal law an individual is disabled if he/she has a physical or mental impairment that substantially limits one or more major life activities has a record of such impairment or is regarded as having such impairment. The term physical or mental impairment includes but is not limited to such diseases and conditions as orthopedic visual speech and hearing impairments cerebral palsy autism epilepsy muscular dystrophy multiple sclerosis cancer heart disease diabetes Human Immunodeficiency Virus infection mental retardation emotional illness drug addiction and alcoholism* This definition doesn t include any individual who is a drug addict is currently using illegal drugs or is an alcoholic who poses a direct threat to property or safety because of alcohol use. 2. Does the household member require what he/she has requested 3. Describe what the household member has requested how this request is related to their disability and describe any other accommodation or modification that could meet the household member s needs in place of what the household member has requested for example if there is a less expensive way to help the household member cope with his/her disability please disclose Name Title of Verification Source please print Firm/Organization Physician Identification Number if applicable 2 of 2.

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