Request from Reasonable Accommodation Form - Fort Worth Housing Solutions

Name

First

Last

Email

TDD/Phone

Address

Street Address

Apartment/Room # (if applicable)

City

State

Zip

I am currently:

An applicant for housing assistance

Receiving housing assistance from FWHS

The following household member has a disability that qualifies under the HUD definition (A physical or mental impairment which substantially limits one or more life activities, or a record of having or being regarded as having such impairment). Enter household member’s name:

As a result of my/his/her disability, the following accommodation is requested so that I/he/she can have the opportunity to equally participate in housing programs at FWHS:

Live-In Aide

Additional Bedroom

Mail-In Recertification

Interpreter for Hearing Impaired

Other:

You may verify the disability and the need for the accommodation by contacting the following medical professional:

Title

Phone

FAX

Address

City/State/Zip

I give you permission to contact the above individual for the purpose of verifying that I or a family member have a disability and need the reasonable accommodation requested above. I understand the information you obtain will be kept completely confidential and used solely to determine whether or not you will provide an accommodation.

Clear

Date

Website/URL

REQUEST FOR REASONABLE ACCOMMODATION