Form HRA-102C "Reasonable Accommodation Request Form" - New York City

What Is Form HRA-102C?

This is a legal form that was released by the New York City Department of Social Services - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 5, 2017;
  • The latest edition provided by the New York City Department of Social Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HRA-102C by clicking the link below or browse more documents and templates provided by the New York City Department of Social Services.

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Download Form HRA-102C "Reasonable Accommodation Request Form" - New York City

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HRA-102c (E) 01/05/2017
(page 1 of 2) LLF
Help for People with Disabilities
Do you have a disability, medical condition or mental health condition that makes it hard
for you to apply for or get benefits from us?
For example:
Does your condition make it hard for you to use public transportation?
Do you need help to get to appointments?
Does your condition make it hard for you to wait for long periods of time?
Is it hard for you to read, understand or fill out forms?
Do you need help because of a vision or hearing disability?
Do you need other help because of your condition?
If you do, we may be able to help you. This help is called a reasonable accommodation.
How to Ask for a Reasonable Accommodation
Ask: You can ask for help when you come to an HRA office or center
Call: 212-331-4640
You can also write us or fill out the request on the other side of this form and give it to
us through:
Fax:
212-331-4685
Email:
ConstituentAffairs@hra.nyc.gov
Mail:
HRA
Office of Constituent Services
150 Greenwich Street, 35th Floor
New York, NY 10007
Get Help with This Form!
You can get help with this form or with your request.
Call 212-331-4640 or Visit your center or HRA office
Turn this page over to complete the Reasonable Accommodation Request Form.
HRA-102c (E) 01/05/2017
(page 1 of 2) LLF
Help for People with Disabilities
Do you have a disability, medical condition or mental health condition that makes it hard
for you to apply for or get benefits from us?
For example:
Does your condition make it hard for you to use public transportation?
Do you need help to get to appointments?
Does your condition make it hard for you to wait for long periods of time?
Is it hard for you to read, understand or fill out forms?
Do you need help because of a vision or hearing disability?
Do you need other help because of your condition?
If you do, we may be able to help you. This help is called a reasonable accommodation.
How to Ask for a Reasonable Accommodation
Ask: You can ask for help when you come to an HRA office or center
Call: 212-331-4640
You can also write us or fill out the request on the other side of this form and give it to
us through:
Fax:
212-331-4685
Email:
ConstituentAffairs@hra.nyc.gov
Mail:
HRA
Office of Constituent Services
150 Greenwich Street, 35th Floor
New York, NY 10007
Get Help with This Form!
You can get help with this form or with your request.
Call 212-331-4640 or Visit your center or HRA office
Turn this page over to complete the Reasonable Accommodation Request Form.
HRA-102c (E) 01/05/2017 (page 2 of 2) LLF
Help for People with Disabilities
Reasonable Accommodation Request Form
Do you have a disability, medical condition or mental health condition that makes it hard
for you to apply for or get benefits from us? If you do, please fill out this form. If you do
not, you don't need to fill out this form.
Your Information
Name: ________________________________________________________ Date: ________________
Case Number: ____________________________________________ Date of Birth: ________________
Phone Number 1: ________________________ Phone Number 2 (if any): ________________________
Address: ____________________________________________________________________________
Why Do You Need Help?
Tell us how your condition makes it hard to access HRA benefits and services (If you need more space to
write, please attach pages): _____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Choose What Help You Might Need Because of Your Condition
__ Help for people who are blind or low vision
Help for people who are deaf or hard of hearing
:
Explain: _____________________
__ American Sign Language (ASL) interpretation
__ Other forms of interpretation
__ Making appointments when you can have
Explain: _______________________________
someone come with you
__ Help reading forms Help completing forms
__ No appointments during certain days and times
__ You need HRA to come to your home for
__ No appointments during rush hour
appointments
__ No in-office appointments while you apply for
__ Transfer your case to center: _____________
Access-A-Ride
__ Keep your case at your center: ____________
__ Shorter wait times
__ Accommodations (other than above) that you need to access services at HRA. Explain: ___________
________________________________________________________________________________
You do not need to give us proof of your condition now.
We may ask you to give us some medical or clinical documents later.
To be completed by HRA worker if submitted at an HRA location (Please give a copy to the client):
Location
Date Received
Signature
Name of HRA worker (Print)
Center 90 Staff only: Homebound status was requested
__
Yes
__
No
Page of 2