REASONABLE ACCOMMODATION OR MODIFICATION REQUEST ...

REASONABLE ACCOMMODATION OR MODIFICATION REQUEST FORM – 2
Regarding:
(Resident’s or Applicant’s Name)
Date of Request:
To:
(Health Care Provider’s – Provider’s – Doctor’s Name)
Company:
(Health Care Provider – Provider – Doctor)
Contact Info:
(Address, Phone, Fax, and Email)
From:
(Name, Title, Company, Apartment Community)
Resident’s Address:
(address or prospective address)
REQUEST FOR A REASONABLE ACCOMMODATION OR
MODIFICATION
[Be sure to substitute Modification for Accommodation when and where appropriate]
The resident named above has applied to or is living in our community. The
resident has requested our permission to: [describe here the specific accommodation
or modification requested] (for example) be let out of his lease without having to pay
any lease break or lease termination fees because the resident has been ordered by the
VA to relocate to a residence that contains panic buttons in every room.
With respect to the requested accommodation, our [community rules / lease ] provide that
[Insert language applicable to request] (example continued) Our lease documents require all
residents who fail to perform all lease obligations, including the obligation of paying rent
through the entire lease term, to pay a lease termination fee or lease break fee. However, if an
individual with disabilities requests permission for an accommodation, we must
consider that request. We must also verify that the individual requires the
accommodation in order to have an equal opportunity to use and enjoy the apartment
and community.
We appreciate your cooperation in answering the questions on this form and returning
it to our community. Enclosed is a stamped, self-addressed envelope for this purpose.
Or, if you’d prefer please feel free to return it to us either by facsimile to the attention of
[name] at [enter fax number], or via e-mail to __[e-mail address]__________. The resident
has consented to the release of the information, as demonstrated by resident’s executed
release, which follows.
Fair Housing Need Defined
Under Fair Housing laws, a person requesting a reasonable accommodation or
modification must demonstrate the necessity of the requested accommodation or
09_0415ReasAccomForm2.doc
- 1 -

REASONABLE ACCOMMODATION OR MODIFICATION REQUEST FORM – 2
modification. Courts have held that any accommodation or modification requested
must be proximately related to the limitation faced by the disabled person. To
preliminarily establish necessity, the disabled individual must demonstrate that the
requested accommodation or modification, if effectuated, would ameliorate the alleged
limitation the disabled individual endures in the use or enjoyment of his dwelling. In
simple terms, the accommodation must serve a disability-related need, i.e. lessen the
impact of the disability.
REQUESTED INFORMATION
Based on the applicable legal requirements set forth above, in your professional
opinion, does the resident need the accommodation or modification requested in order
to have the same opportunity that a non-disabled individual has to use and enjoy the
apartment or community?
___Yes ___ No
Name and Title of person supplying Information
__________________________________________________________
Firm/Organization
__________________________________________________________
Would you be willing to testify in any court action or related proceeding as to the
Resident’s need for the accommodation or modification?
____ Yes ____ No
Signature: __________________________________ Date: __________
Print Name: _________________________________
Resident’s Verification of Information and Release
TO THE RESIDENT OR PROSPECTIVE RESIDENT:
YOU DO NOT HAVE TO SIGN THIS FORM IF THE NAME OR ADDRESS OF EITHER
THE COMMUNITY OR THE HEALTH CARE PROVIDER IS LEFT BLANK
RELEASE: By signing below, I acknowledge that I have carefully reviewed the
foregoing Reasonable Accommodation or Modification Request Form, that the
information contained therein is accurate, and that the request for a reasonable
accommodation or modification as set forth above is the exact request that I have
made of the property or landlord. I hereby authorize the release of the requested
information. Information obtained under this consent is limited to information that
is no older than 12 months. There are circumstances, which would require the
community to verify information that is up to 5 years old, which would be authorized
by me on a separate consent, attached to a copy of this consent.
Signature: _____________________________Date: __________
Print Name: ______________________________________
09_0415ReasAccomForm2.doc
- 2 -

REASONABLE ACCOMMODATION OR MODIFICATION REQUEST – SAMPLE
LETTER 2
Instructions on Use – Use this letter when a resident’s disability is known but the need
for the accommodation or modification is not obvious. This letter should be used to
document the request and the handling of the request when the resident will not
cooperate and complete “Reasonable Accommodation or Modification Request Form-
2.” Be sure to substitute Modification for Accommodation when and where it is appropriate for
your scenario.
Scenario for Sample Letter 2 – You have a resident in a wheelchair. The resident does
not drive. The resident wants a close-up reserved parking space so that family
members who visit him can park close to his unit.
Evaluation –
Is resident or somebody associated with the resident disabled? Yes.
Is the need for the accommodation apparent? No.
KEY Points Regarding Reasonable Accommodation/Modification Documentation
Letters
Documentation should always include both
a) [if disability at issue] what facts are known to you regarding the resident’s or
prospect’s disability based both on what you have been told and on your own
observations;
and
b) [if need at issue] what facts are known to you regarding the resident’s or
prospect’s need for the accommodation or modification based both on what
you have been told and on your own observations.
[TEXT OF SAMPLE LETTER FOLLOWS]
DATE:
TO: RESIDENT [insert name]
RE: YOUR REQUEST FOR A REASONABLE ACCOMMODATION or
MODIFICATION
Dear Resident [insert name]:
This letter documents your recent request for a reasonable accommodation.
Specifically, the community does not have assigned or reserved parking spaces. On or about
_____, you approached our resident manager, , and asked for an exception to
this rule. Specifically, you asked for a close-up reserved parking space so that your family
members can park close to your unit when they visit. If this was not your specific request,
we would appreciate it if you would advise us of your exact request, preferably in
writing, at your earliest convenience.
Because you asked for an exception to the community’s [Insert applicable language
from lease or rules] parking rules, we have interpreted your request as a request for a
reasonable accommodation under the fair housing laws. Since [INSERT COMMUNITY
OR MANAGEMENT COMPANY] is fair housing provider, we consider all requests for
09_0415ReasAccomLetter2.doc
- 1 -

REASONABLE ACCOMMODATION OR MODIFICATION REQUEST – SAMPLE
LETTER 2
reasonable accommodations. Accordingly, we now respond to your request for a
reasonable accommodation.
In order to grant [DESCRIBE OR INSERT REQUEST] a close-up reserved parking
space as a reasonable accommodation under fair housing laws, you must be disabled
within the meaning of fair housing laws, and the request must be necessary in general.
Specifically there must be a relationship (a nexus) between the request and the
requestor’s disability, and the request must be reasonable. To preliminarily establish
necessity, you must demonstrate that if the requested accommodation were to be
granted, it would ameliorate the claimed limitation that you endure in the use or
enjoyment of your rental. In simple terms, the accommodation must serve a disabilityrelated
need, i.e. lessen the impact of your disability.
Based on the totality of information available to us at this time, we must
unfortunately deny your request for [INSERT REQUEST] a close-up reserved parking
space. We want to make it clear that this is not our final position on the matter. We are
committed to and always open to a dialog on this issue. Upon providing the
information requested, or if you would like to advise us of further information
regarding your request for [INSERT REQUEST] a close-up reserved parking space,
addressing the specific legal requirements set forth in this letter, we will promptly
consider and evaluate any information that you provide.
If you wish to discuss this matter further, please do not hesitate to contact me.
09_0415ReasAccomLetter2.doc
- 2 -