Request for Reasonable Accommodation

This form is to be used by an individual with a disability who is applying for housing assistance or who is currently a participant in the programs administered by DHA Housing Solutions for North Texas. This form is used to request an accommodation, i.e., a change, an exception, or an adjustment to a rule, policy, practice, or service, or a modification that may be necessary for a person with a disability to have an equal opportunity to use and enjoy a dwelling.

This form should be completed by the applicant/participant with a disability, unless such individual is a minor or cannot complete the form as a direct result of his/her disability. In such case, the designee of the applicant/participant or the responsible adult may complete the form.

If you need assistance in filling out this form or communicating your request for a reasonable accommodation to DHA, notify a DHA staff member for assistance. For additional information, contact the Disability Rights Coordinator at 469-965-1961; or 7-1-1 Relay Texas Assistance; or at e-mail DisabilityRights@dhantx.com.

Request for Reasonable Accommodation

"*" indicates required fields

1. Head of household information

First Name*

Last Name*

Date of Birth

Phone

Street Address*

Street Address 2

City*

State*

Zip Code*

Email (Head of Household)*

Which DHA program do you receive assistance from?*

Public Housing (You live in a DHA-owned property)

Housing Choice Voucher (You rent your home in the private market)

Other

Which DHA residential community do you live in?*

2. Individual with a disability requesting the accommodation

First Name*

Last Name*

Date of Birth

Phone*

Street Address

Street Address 2

City

State

Zip Code

Relationship to the Head of Household

Email (Person with a Disability)

3. Name of person filling out this form, if not the individual listed in sections 1 and 2 above

First Name

Last Name

Relationship to the Individual Listed in No. 2 Above

Email (Person completing this form)

4. I need the following accommodations as a result of my disability (be specific about what you need without disclosing the nature and extent of your disability/medical condition)

Accommodation Needs

5. If you are requesting a live-in aide, you must answer the following questions:

Prospective Live-In Aide First Name

Last Name

Is Your Prospective Live-In Aide a Current Member of Your Household?

Yes

Note: DHA policy does not allow a current member of the household to serve as live-in aide for that household.

6. In response to a request for a reasonable accommodation, DHA may request reliable disability-related information that (1) is necessary to verify that the person has a physical or mental impairment that substantially limits one or more major life activities, (2) describes the needed accommodation, and (3) shows the relationship between the person’s disability and the need for the requested accommodation.

For purposes of this verification process, provide the following:

Full name (first and last name) of a doctor or other medical professional, peer support group, non-medical service agency, or reliable third party who is in a position to know about the individual's disability and who may provide verification of a disability:

First Name

Last Name

Title of this doctor or other medical professional, peer support group, a non- medical service agency, or reliable third party

Complete mailing address of this doctor or other medical professional, peer support group, non-medical service agency, or reliable third party

Street Address

Street Address 2

City

State

Zip Code

Telephone; fax number; and email address of this doctor or other medical professional, peer support group, non-medical service agency, or reliable third party

Phone

Fax

Email Address

Authorization for Release of Information

I acknowledge and agree

By ticking this box, I authorize DHA to contact the healthcare professional listed in #6 above to verify that I, or a member of my assisted family, have a disability and need the accommodation specified above in #4, which is needed as a direct result of this disability. I acknowledge that I am a person authorized to sign this release. I understand that the information to be obtained will be kept confidential and will be used solely for the purpose of determining if the accommodation I have requested can be provided. Please be advised you are not authorized to move out of your current unit until your relocation has been approved.

The Fair Housing Act prohibits discrimination in housing based on color, race, religion, national origin, sex, familial status, or disability.

Request for Reasonable Accommodation