REASONABLE ACCOMMODATION VERIFICATION FORM
Date of
Request:
03/13/2025
Address of Resident:
Name of Resident: ----------------
--------------
Phone No. of Resident:
I.
Describe the specific accommodation requested:
2.
Explain why this accommodation is necessary, as a direct result of the resident's disability, to allow the
resident full
enjoyment
of
the
premises:
3.
The individual seeking an accommodation is a person with a disability according to the following
definition:
A physical or mental impairment that substantially limits one or more major life activities, a record of
having such an impairment, or being regarded as having such an impairment.
:v'_ Yes
No
□
[For further guidance on the definition of a disability see Appendix A.]
4.
Describe the problem (if applicable) that the person for whom the reasonable accommodation is
requested is having with the dwelling, building, property, practice, rule, policy, procedure, program or
service:
5.
If applicable, please indicate what features or conditions must be present in any dwelling in which the
resident requesting the reasonable accommodation might live: .
6.
Describe the type of change, feature or assistance required:
7.
Please describe the relationship between the functional limitations of the person for whom the
accommodation is requested and the requested accommodation. Do not provide unnecessary details about
the medical history or disabled status of the person seeking an accommodation:
Date:
03/13/2025
Signature:
Cl (act.la
Printed Nan@
Professional Title:
Address:
City/State/Zip:
_0alas.7715@3
Phone
No.:
Fax No.:
------------------
APPENDIX A
Definition of a Individual With a Disability
( 1)
For the purpose of determining whether civil rights protections apply, a person is an "individual with a disability" if
he or she has, or has a record of having, or is regarded as having, a physical or mental impairment which
substantially limits one or more of his or her major life activities 1 • There are three necessary elements to this
definition:
a.
b.
c.
A physical or mental impairment
Which substantially limits
One or more of the person's major life activities.
All three elements must be present. However, a person is not an "individual with a disability" ifhe or she is a current illegal
user of a controlled substance2 (illegal drugs which have not been prescribed by a medical provider).
(2)
A "physical impairment" is any physiological disorder or condition, loss, disease or disfigurement which affects one
or more body systems. A physical impairment can be caused by illness, disease, a birth defect, injury, age or any
other cause that disrupts a person's physical ability to function. A physical impairment includes, but is not limited
to:
a.
b.
C.
d.
(3)
C.
Cancer
Heart Disease
Epilepsy
Arthritis
Mental illness
Mental retardation
Alcoholism3
d.
e.
f.
Past drug use (only in certain conditions)
Emotional disorders or illness
Specific learning disabilities
A physical or mental impairment "substantially limits" a person in one or more "major life activities" if it causes
substantial difficulty in a person's ability to:
a.
b.
C.
1
e.
f.
g.
h.
A "mental impairment" is any mental, psychiatric or psychological disorder. A mental impairment includes, but is
not limited to:
a.
b.
(4)
Cerebral Palsy
AIDS and HIV infection
Visual impairment
Hearing impairment
See, hear, speak or breathe
Learn, think or read
Work, walk or perform manual tasks
d.
e.
Care for himself or herself
Engage in some other "major life activity"
A person who fits this definition only because he or she is regarded or perceived as disabled but does not actually have a
disability or a history of an actual disability is protected by law against discrimination but does not have a right to reasonable
accommodation. This is because the accommodation would not be necessary to provide him or her with an equal opportunity
to use and enjoy the housing.
2
"Controlled substances" are those drugs which are identified at 21 U.S.C. § 802, but they do not include alcohol.
3
Under the applicable federal civil rights statutes, alcoholism is considered an impairment in the context of housing
programs. However, where a person's abuse of alcohol would interfere with the health, safety or right to peaceful enjoyment
by other residents, he or she would not be "otherwise qualified" for certain housing programs.