44 Harry Kemp Way Provincetown, MA 02657 PHA@ProvincetownHousing.org 508-487-0434

REQUEST FOR REASONABLE ACCOMMODATION

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offices.

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ل م كات ب نا.  TELEPHONE NUMBER 508-487-0434

REQUEST FOR REASONABLE ACCOMMODATION

This form is to be completed by the head of household on behalf of the household

member needing the accommodation and it must be signed by both the Head and the

household member if 18 years of age or older.

Name of Person Whom Needs the Accommodation: ________________________________

Name of Head of Household: ___________________________________________________

Address: __________________________________________________ Unit# ____________

Daytime Phone#: _____________________________________________________________

1. I am a person with a disability as defined by one or more of the following: A physical or

mental impairment that substantially limits one or more life activities; or a record of

having such an impairment; or is regarded as having such an impairment.

**lf I am not the person with a disability, the following member of my household has a

disability as defined above:

Name: _________________________________________________________________

Relationship to you (e.g. child, parent):________________________________________

Please be sure you have filled out all pages of this form.

Page 1 of 3

2.As a result of this disability, I am requesting the following reasonable accommodation

for my household:

(Please check one or more boxes below).

( ) A change in my apartment or other part of the housing development. Please

Specify: ________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

( ) A change in the following rule, policy or procedure. (Note that a change in how to meet the terms of the lease may be requested, but the terms of the lease must be met.) Please specify:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

( ) Other (for example, a change in the way the MHA communicates with you). Please specify:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

3.This request for reasonable accommodation is necessary so that I can:_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

4.I authorize the Malden Housing Authority to verify that I have or someone in my household has a disability and we have the need for the reasonable accommodation I have requested. In order to verify this information the MHA may contact the following physician, psychiatrist, licensed psychologist, licensed nurse practitioner, licensed social worker, rehabilitation professional, or non-medical service agency whose function is to provide services to the disabled, or other expert in the field of ____________________.(Note: You may present verification directly to the MHA).

Please be sure you have filled out all pages of this form.

Page 2 of 3

Name of Provider: _____________________________________________________________

Title of professional or expert: __________________________________________________

Agency/Clinic/Facility: _________________________________________________________

Address: ____________________________________________________________________

Telephone: __________________________________________________________________ 

Fax: ________________________________________________________________________

I understand that the information obtained by the MHA will be kept completely confidential and used solely to make a determination on my reasonable accommodation request.

Please return this form as promptly as possible so that the MHA may make a determination on this request.

Signed: ______________________________________________________________________________

[**Head of household or authorized guardian]

Signed: ______________________________________________________________________________

[**Adult household member needing the accommodation, 18 years of age or older]

Date: __________________________

**lf on behalf of a minor child, please indicate whether you are the parent or guardian. Where the individual with the disability is over 18 and is not the head of household, s/he must sign the authorization for verification.

Please be sure you have filled out all pages of this form.

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