REASONABLE ACCOMMODATION OR MODIFICATION REQUEST FORM 3

Transcription

1 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 ) From: (Name, Title, Company, Apartment Community) Resident s Address: (address or prospective address) REASONABLE ACCOMMODATION OR MODIFICATION REQUEST FORM [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] With respect to the requested accommodation or modification, our [community rules / lease ] provide that [Insert language applicable to request]. However, if an individual with disabilities requests permission for an accommodation or modification, we must consider that request. We must also verify that the individual qualifies as disabled under federal law and requires the accommodation or modification 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 to [ address]. The resident has consented to the release of the information, as demonstrated by resident s executed release, which follows. Definition of Disabled Under federal law, an individual is disabled if he /she has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such an impairment. The term physical or mental impairment includes, but is not limited to, such diseases

2 and conditions as orthopedic, visual, speech, and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, Human Immunodeficiency Virus infection, mental retardation, emotional illness, drug addiction, and alcoholism. This definition does not include any individual who is a drug addict and is currently using illegal drugs or an alcoholic who poses a direct threat to property or safety because of alcohol use. Major life activities include but may not necessarily be limited to caring for one s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. A limitation is substantial if it significantly restricts the condition, manner, or duration under which an individual can perform a particular major life activity as compared to the condition, manner, or duration under which the average person in the general population can perform that same major life activity. 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 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 disable 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 or modification must serve a disability-related need, i.e. lessen the impact of the disability REQUESTED INFORMATION 1. Is the resident disabled as defined above? Yes No 2. 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 3. Please identify how long you have treated or provided services to this person: Name and Title of person supplying Information Firm/Organization 4. Would you be willing to testify in any court action or related proceeding as to the Resident s need for [the accommodation / modification]? Yes No - 2 -

3 If you checked No for question #4, please provide an explanation: 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: - 3 -

4 REASONABLE ACCOMMODATION OR MODIFICATION REQUEST SAMPLE LETTER 3 Disability Not Known or Obvious, and Need Not Known or Obvious. Instructions on Use Use this letter when both a resident s disability and the need for an accommodation or modification are 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- 3. Be sure to substitute Modification for Accommodation when and where it is appropriate for your scenario. Scenario for Sample Letter 3 A resident has asked that the property s pet fee policy ($ per pet) be waived because she suffers from depression and the animals comfort her. Based on your observation of the resident, the resident does not appear to be disabled. Evaluation Is resident or somebody associated with the resident disabled? Not apparent or obvious. Is the need for the accommodation or modification apparent? No. Documentation should always include both a) 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) 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 allows pets but only if you pay the $ pet fee for each animal. On or about, you approached our resident manager, and asked for an exception to this rule. Specifically, you asked that the property waive our pet fees for you because you need the pets for therapeutic reasons. 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 pet fee policy, 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 reasonable accommodations. Accordingly, we now respond to your request for a reasonable accommodation. 09_0415ReasAccomLetter3.doc - 1 -

5 REASONABLE ACCOMMODATION OR MODIFICATION REQUEST SAMPLE LETTER 3 In order to [DESCRIBE OR INSERT REQUEST] waive pet fees as a reasonable accommodation under fair housing laws, you must be disabled within the meaning of fair housing laws. Under applicable fair housing laws, a person is considered disabled if he or she has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such an impairment. The term physical or mental impairment includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, Human Immunodeficiency Virus infection, mental retardation, emotional illness, drug addiction, and alcoholism. This definition does not include any individual who is a drug addict and is currently using illegal drugs or an alcoholic who poses a direct threat to property or safety because of alcohol use. Major life activities include but may not necessarily be limited to caring for one s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. A limitation is substantial if it significantly restricts the condition, manner, or duration under which an individual can perform a particular major life activity as compared to the condition, manner, or duration under which the average person in the general population can perform that same major life activity. In addition to meeting the definition of disabled within the meaning of fair housing laws as described above, the request must also be necessary. 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 disability-related 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 waiver of pet fees. 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 waiver of pet fees for your pets, 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_0415ReasAccomLetter3.doc - 2 -