RC Request Form - NHE Inc



(INSERT PROPETY NAME)

REASONABLE ACCOMMODATION REQUEST FORM FOR AN ASSISTANCE ANIMAL

INSERT PROPERTY NAME is committed to the letter and spirit of the Fair Housing Act and Section 504, which, among other things, prohibits discrimination against persons with disabilities. In accordance with our statutory responsibilities and management policies, we will make reasonable accommodations in our rules, policies, practices, or services, when such accommodations may be necessary to afford persons with disabilities an equal opportunity to use and enjoy their housing communities. If you are requesting such an accommodation, please fill out this form and return it to the manager at (INSERT PROPERTY NAME AND ADDRESS).

(Please Print)

Applicant and/or Resident Name:

Address: Date of Request:

Please describe the assist animal that is an exception to our usual pet policy that you are requesting:

Under the Fair Housing Act, a “disability” is a physical or mental impairment, which substantially limits one or more of a person’s major life activities, a record of having such an impairment, or being regarded as having such an impairment.

1. Do you consider yourself to have a disability as defined by the Fair Housing Act?

YES NO If “NO” is checked, skip 2 and 3.

2. Are you requesting a specific animal to provide assisted services to you because of your disability? 

YES NO

 

If yes, please describe the animal that you are requesting as a reasonable accommodation:

Type of animal (i.e., dog, cat): Name of animal:

Breed (if dog): Height and weight:

Length of time you have owned this animal Number of other animals currently residing in household:

3. Please describe how the requested accommodation is necessary for your use and enjoyment of your apartment community? (If needed, you may write on the back of this form or attach additional sheets of paper.) If you are requesting an animal, please describe why this specific animal is necessary because of your disability.

Upon Request, please provide the contact information for a professional third party verifier to whom we will send the required verification form.

(Please print)

Name: Position:

Address:

Telephone:

Resident Signature:

Date:

PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 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 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 408 a(6)(7) and (8).

“Owner or project name” 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 nondiscrimination requirements against persons with disabilities.

Patricia Sherman

Name

401 Harbison Blvd., Suite 3

Address

Columbia SC 29212

City State Zip

( 803 ) 536-1056

Telephone - Voice

( 800 ) 735-8583

Telephone – TTY

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