Reasonable Accommodation Request

Notice of Right to Reasonable Accommodation

Name(Required)

Date of Request(Required)

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Address

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Address Line 2

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

1. My household is:

Please note that BangorHousing cannot grant some requests for those who have or are applicants for Section 8 (Housing Choice) vouchers. These requests must be presented to those tenants’ owners/landlords.

2. The following member of my household has a disability:

Under state and federal law, an individual is considered disabled if they have a physical or mental impairment that substantially limits one or more of their major life activities; has a record of such an impairment; is regarded as having such an impairment; or, under state law, requires special education, vocational rehabilitation or related services.

3. As a result of this disability, the following accommodation is requested:

4. This accommodation is necessary because:

4. By signing below, I authorize BangorHousing to verify that I or a member of my household has a disability and have a need for the specific accommodation requested. I also authorize the provider/practitioner listed below to complete and return the Reasonable Accommodation Verification Form to BangorHousing and to answer any other questions BangorHousing may have concerning this request. Information obtained under this authorization is limited to information from the last 12 months.

In order to verify the information in this Request Form, BangorHousing may contact:

Provider/Practitioner Name/Title

Address

State

Two letter state abbreviation

Zip Code

Phone

Fax

Signature(Required)

Date(Required)