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Sample Reasonable Accommodation Form PID3(AutoSave)

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Ronald Stiefel
I, Stephen Fry, have been diagnosed with a Anxiety Disorder and Post Traumatic Stress Disorder
] disability by my licensed mental health professional (see attached letter). As a result, I am
requesting reasonable accommodation for my disability under the Fair Housing Act. Fortunately, my
reasonable accommodation does not require any physical modification of the interior or exterior of
the dwelling. In this case, my reasonable accommodation is “an exception or change that a housing
provider makes to rules, policies, services or regulations that will assist a resident or applicant with a
disability to take full advantage of a housing program and/or dwelling.” I am simply requesting
reasonable accommodation of my disability that allows me to live with my emotional support
animal(s) in order to afford me the “equal opportunity to use and enjoy my dwelling”. Furthermore,
I understand that I am responsible for any damage associated with my emotional support animal
beyond what is considered normal wear and tear.
Should you deny my reasonable accommodation, please reply in writing the reason(s) why you are
denying my request so that I expressly know that I am not being treated differently because of my
If you have any questions regarding your responsibility toward disabled individuals like me, please
search for and read the U.S. Department of Housing and Urban Development (HUD) FHEO Notice:
I look forward to being provided reasonable accommodation.
I expect any intentionally or
accidentally revealed or inferred medical history, including my diagnosis and treatment, and this
request for reasonable accommodation to remain confidential and protected.
Stephen Fry