REQUEST FOR REASONABLE ACCOMMODATION – Provincetown Housing Authority

This is an important document. If you require interpretation, please call the telephone number below or come to our

offices.

Este é um documento importante. Se você precisar de interpretação, por favor, ligue para o número abaixo ou vir para

os nossos escritórios. 这是一份重要文件。如果您需要解释，请拨打下面的电话号码，或来我们的办事处。

這是一份重要檔。如果您需要解釋，請撥打下麵的電話號碼，或來我們的辦事處。

Dit is een belangrijk document. Wenst u een interpretatie, bel het volgende telefoonnummer of naar ons kantoor komen.

Il s’agit d’un document important. Si vous avez besoin d’interprétation, veuillez appeler le numéro de téléphone ci-dessous ou

venir à nos bureaux. I ונלש םידרשמב אובל וא ןלהל ןופלטה רפסמל רשקתהל אנ ,תונשרפ תשרדנ םא .בושח ךמסמ והז

Questo è un documento importante. Se si richiede di interpretazione, si prega di chiamare il numero di telefono qui sotto o venire

ai nostri uffici. これは重要な文書です。通訳が必要な場合は、下記の電話番号に電話か私たちのオフィスに来てください。이것

은 중요한 문서를 .합니다 해석이 필요할 경우 아래 전화 번호로 전화를 또는 우리의 사무실로 와서.

Jest to ważny dokument. Jeśli wymagana jest interpretacja, wywołać numer telefonu poniżej lub wejść do naszego biura.

Это является важным документом. Если вы требуют интерпретации, позвоните ниже номер телефона или прийти к нам в

офис. Se trata de un documento importante. Si usted requiere interpretación, por favor llame al número telefónico que aparece a

continuación o venir a nuestras oficinas. Αυτό είναι ένα σημαντικό έγγραφο. Εάν απαιτείτε την ερμηνεία, παρακαλώ καλέστε τον

αριθμό τηλεφώνου κατωτέρω ή ελάτε στα γραφεία μας. Detta är ett viktigt dokument. Om du kräver tolkning, behaga appellen det

nedanföra telefonnummer eller komm till våra kontor و أ ھاندأ فتاھلا مقرب لاصتالا ﯩجري ،ریسفت ﯩلإ جاتحت تنك اذإ .ةماه ةقیثو اذه

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.

Page 3 of 3