RESIDENT’S REASONABLE ACCOMMODATION REQUEST FORM



NHE, Inc.

Insert Property Name Here

ESSENTIAL CARE GIVER/LIVE-IN AIDE VERIFICATION FORM

Insert Property Name Here provides reasonable accommodations to applicants and/or residents with disabilities who have a verifiable need for the reasonable accommodation. A reasonable accommodation is an exception made to the usual rules or policies made necessary because of a disability for the applicant and/or resident to use and enjoy an apartment community. The applicant and/or resident has authorized you to provide the information requested on this form. Please answer the following questions and return to the Manager at Insert Property Address

• The below listed resident lives in an apartment at this property.

• This property receives Federal funds through the Department of Housing and Urban Development or Rural Development

• To receive Federal funds, we must adhere to strict policies concerning the eligibility of our residents.

• We consider a request for a live-in aide as a request for a reasonable accommodation and as an exception to our usual resident selection and qualification criteria.

• We consider an effort to obtain housing for an ineligible person who is not legitimately needed as a live-in aide to be fraud.

The resident’s signature below authorizes you to provide information concerning this resident’s request for a full time live-in aide to occupy his/her apartment.

Resident’s printed name: __________________________________________________________________

Signature: ______________________________________________________________________________

The Fair Housing Act and Section 504 defines disability as a physical or mental impairment that substantially limits one or more major life activities. The Supreme Court has determined that to meet this definition a person must have an impairment that prevents or severely restricts the person from doing activities that are of central importance in most peoples’ daily lives.

1. Does this applicant and/or resident have a disability?

□ YES □NO □ I DON’T KNOW

If the answer is NO then stop here and sign below.

2. If the resident/applicant is disabled, is it necessary for this resident to obtain the full time services of a live-in aide to be able to successfully live in this property, perform daily living activities, and meet the lease terms? Please be aware that it is not adequate to state that the resident will merely “benefit” from the services of the live-in aide. The services provided by the aide must necessary.

□ YES □ NO □ I DON’T KNOW

3. Does this resident need full time assistance to perform personal daily activities?

□ YES □ NO □ I DON’T KNOW

4. If yes, is this need expected to continue for longer than six months?

□ YES □ NO □ I DON’T KNOW

5. Does this resident need the accommodation requested above to be able to live in their apartment community?

□ YES □ NO □ I DON’T KNOW

6. If necessary, would you be willing to testify to the information provided in this form in a court of law?

□ YES □ NO

7. Requesting a Live-In Aide is considered a reasonable accommodation.

The following is the name and address of the person that is being requested to be the live-in aide.

8. Do you know if this named person will be able to provide the services needed by the resident?

□ YES □ NO □ I DON’T KNOW

Name: ___________________________________________________________________________________

Address: __________________________________________________________________________________

Telephone: _______________________________________________________________________________

(Please Print)

Name: ___________________________________________________________________________________

Position of Verifier: ________________________________________________________________________

Signature of Verifier: ____________________________________________ Date: ______________________

Address: ________________________________________________________________________________

Telephone: _______________________________________________________________________________

Insert Property Name Here does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.

The person named below has been designated to coordinate compliance with the non-discrimination requirements contained in the Department of Housing and Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988).

Patricia Sherman

Name

401 Harbison Blvd., Suite 3

Address

Columbia SC 29212

City State Zip

803-937-3544

Telephone-Voice

1-800-735-8583

Telephone-TTY

PENALTIES FOR MISUSING THIS CONTENT: Title 18, Section 101 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of any of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 USC 208 a(6)(7) and (8). Violations of these provisions are cited as violations of 42 USC 208 a(6)(7) and (8).

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