"Reasonable Accommodation Request Form" - New York City

Reasonable Accommodation Request Form is a legal document that was released by the New York City Department of Housing Preservation and Development - a government authority operating within New York City.

Form Details:

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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New York City Department of Housing Preservation and Development.

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MARIA TORRES-SPRINGER
Office of Financial Management
Commissioner
and Tenant Resources
DON SHACKNAI
Division of Tenant Resources
First Deputy Commissioner
100 Gold Street
EVA TRIMBLE
New York, N.Y. 10038
Deputy Commissioner
LAURIE LoPRIMO
Assistant Commissioner
nyc.gov/hpd
REASONABLE ACCOMMODATION REQUEST
To the Participant or Applicant: Complete this page to request an exception to an HPD rental assistance policy or procedure, such as
a larger voucher size or moving in the first year of your lease. HPD may approve the request if a connection is made between the
disability of the household member and the reasonable accommodation request. For the purpose of reasonable accommodation, a
person has a disability if they: have a physical or mental impairment that substantially limits one or more major life activities; have a
record of such impairment, or are considered as having such impairment. Below, name the health care provider responsible for services
related to your disability and have that person complete the Reasonable Accommodation Verification on the next page. Return the
completed forms by mail, fax, or email to the contact below. If you have questions, please call Client Services: 917-286-4300.
PARTICIPANT / APPLICANT: HOUSEHOLD INFORMATION
Head of Household:
Phone Number:
Date:
Street Address:
Email:
Name of person requesting reasonable accommodation:
PARTICIPANT / APPLICANT: ACCOMMODATION REQUEST
Describe specifically what is needed to accommodate your disability:
Describe why this accommodation is needed for your disability:
Name of Health Care Provider:
Phone Number:
Address:
Fax:
I certify that the above statements are true to the best of my knowledge. I understand that supplying false statements and
information can lead to a denial of my reasonable accommodation request and jeopardize my housing subsidy. I authorize the
NYC Department of Housing Preservation and Development to verify my eligibility for the accommodation requested. To
verify this information, I authorize HPD to contact the health care provider listed above and allow the provider to release
information to HPD.
Please return completed forms to:
NYC Department of Housing Preservation and Development
Requestor’s Signature (if under 18, parent or legal guardian)
Date
Division of Tenant Resources
100 Gold St., Rm. 4Z2C, New York, NY 10038
Attn: Executive Assistant
FAX: 212-863-5299
EMAIL: DTRAI@hpd.nyc.gov
MARIA TORRES-SPRINGER
Office of Financial Management
Commissioner
and Tenant Resources
DON SHACKNAI
Division of Tenant Resources
First Deputy Commissioner
100 Gold Street
EVA TRIMBLE
New York, N.Y. 10038
Deputy Commissioner
LAURIE LoPRIMO
Assistant Commissioner
nyc.gov/hpd
REASONABLE ACCOMMODATION REQUEST
To the Participant or Applicant: Complete this page to request an exception to an HPD rental assistance policy or procedure, such as
a larger voucher size or moving in the first year of your lease. HPD may approve the request if a connection is made between the
disability of the household member and the reasonable accommodation request. For the purpose of reasonable accommodation, a
person has a disability if they: have a physical or mental impairment that substantially limits one or more major life activities; have a
record of such impairment, or are considered as having such impairment. Below, name the health care provider responsible for services
related to your disability and have that person complete the Reasonable Accommodation Verification on the next page. Return the
completed forms by mail, fax, or email to the contact below. If you have questions, please call Client Services: 917-286-4300.
PARTICIPANT / APPLICANT: HOUSEHOLD INFORMATION
Head of Household:
Phone Number:
Date:
Street Address:
Email:
Name of person requesting reasonable accommodation:
PARTICIPANT / APPLICANT: ACCOMMODATION REQUEST
Describe specifically what is needed to accommodate your disability:
Describe why this accommodation is needed for your disability:
Name of Health Care Provider:
Phone Number:
Address:
Fax:
I certify that the above statements are true to the best of my knowledge. I understand that supplying false statements and
information can lead to a denial of my reasonable accommodation request and jeopardize my housing subsidy. I authorize the
NYC Department of Housing Preservation and Development to verify my eligibility for the accommodation requested. To
verify this information, I authorize HPD to contact the health care provider listed above and allow the provider to release
information to HPD.
Please return completed forms to:
NYC Department of Housing Preservation and Development
Requestor’s Signature (if under 18, parent or legal guardian)
Date
Division of Tenant Resources
100 Gold St., Rm. 4Z2C, New York, NY 10038
Attn: Executive Assistant
FAX: 212-863-5299
EMAIL: DTRAI@hpd.nyc.gov
MARIA TORRES-SPRINGER
Office of Financial Management
Commissioner
and Tenant Resources
Division of Tenant Resources
DON SHACKNAI
First Deputy Commissioner
100 Gold Street
EVA TRIMBLE
New York, N.Y. 10038
Deputy Commissioner
LAURIE LoPRIMO
Assistant Commissioner
nyc.gov/hpd
REASONABLE ACCOMMODATION VERIFICATION
To be completed by a medical professional
To the Health Care Provider: The NYC Department of Housing Preservation and Development (HPD) provides reasonable
accommodation to a household who is either applying for, or receiving, rental assistance in order to allow equal access to the program.
HPD may grant an exception to an HPD rental assistance policy or procedure if a connection is made between the disability of the
household member and the reasonable accommodation request. The person completing this request has listed you as a health care
professional that can verify the need for reasonable accommodation. Please only include medical information below that is directly
relevant to the request for a reasonable accommodation.
PARTICIPANT / APPLICANT: REQUEST INFORMATION
Head of Household:
Person Requesting Accommodation:
Requested Accommodation:
HEALTH CARE PROVIDER: VERIFICATION OF DISABILITY
For the purpose of reasonable accommodation, a person has a disability if they: have a physical or mental impairment that substantially
limits one or more major life activities; have a record of such impairment, or are regarded as having such impairment.
Does the above named individual meet this definition of disabled?
Yes
No
If yes, which major life activities are affected?
HEALTH CARE PROVIDER: CONNECTION BETWEEN DISABILITY AND REQUESTED ACCOMMODATION
Is there a connection between the requested accommodation and the person’s disability?
Yes
No
If yes, how is the accommodation linked to the person’s disability? (Note: in order for an accommodation to be considered, a
connection must be made between the disability and the requested accommodation.)
HEALTH CARE PROVIDER: CERTIFICATION
I certify that the information above is accurate and true to the best of my knowledge.
Name:
Title:
Signature:
Date:
Phone Number:
License Number:
Agency Name:
Health Care Provider: Place medical stamp below.
Please return completed forms to:
NYC Department of Housing Preservation and Development
Division of Tenant Resources
100 Gold St., Rm. 4Z2C, New York, NY 10038
Attn: Executive Assistant
FAX: 212-863-5299
EMAIL: DTRAI@hpd.nyc.gov
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