RE: Verification of Need for Special Accommodation for Disabled Applicant/Resident for:

(Applicant/Resident Name)

(Mailing Address) (City)(State)(Zip Code)

To Whom It May Concern:

The above listed person has applied for admission to or currently resides in our housing community and has indicated the need for a special accommodation based upon a handicap or disability. The specific request is found on the attached “Options for Applicants or Residents with Disabilities” form completed by the above person.

In order for us to accommodate the request listed we need written verification from a health professional that 1) the applicant/resident meets one of the following definitions of a handicap or disability, and 2) that the accommodation listed will increase the applicant’s/resident’s quality of life at our community. Please verify this information in the “Health Care Provider” section listed on page 2. The information you provide will remain confidential.

Please complete and return page 2 of this letter immediately, in the enclosed stamped, self-addressed return envelope. If you have any questions, please call the telephone number listed below.



Owner/Owner’s Agent SignatureTelephone Number


RELEASE: I hereby authorize the release of the requested information to verify my special accommodation request. Please see the attached “Options for Applicants or Residents with Disabilities” form that I completed.


Applicant/Resident SignatureDate


Applicant/Resident Printed NameSocial Security or Medical Record Number

DISABILITY DEFINITION: (Per Fair Housing guidelines.)

Any person who 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 impairment. Examples follow:

  • “Physical impairment” – any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting any of the major body systems. This includes persons testing HIV positive, whether or not they are asymptomatic of AIDS.
  • “Mental impairment” – any mental or psychological disorder. Examples include mental retardation, organic brain syndrome, emotional or mental illness, specific learning disabilities, autism, alcoholics and recovering drug addicts.
  • “Major life activities” – functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working.
  • “Record of” – the person has a history of having a covered impairment, even if the person is not currently impaired, and even if the history is incorrect.
  • “Regarded as” – having a physical or mental impairment that substantially limits a major life activity, whether or not that person actually has an impairment.

HEALTH CARE PROVIDER: Please check only the “Yes” or “No” box.

No The above named individual does not qualify as handicapped or disabled under any of the definitions above.

Yes The above named individual qualifies as handicapped or disabled under at least one of the above definitions.

“If” this box is checked, please establish a “link” between the applicant’s/resident’s disability and the need

for the special accommodation requested and attached to this letter by answering questions 1 and 2 below:

1) The requested accommodation is considered appropriate to enable the disabled applicant/resident to enjoy the premises to the same degree as that of a similarly-situated non-disabled person. Please explain the



2) The similar concept of necessity requires at a minimum the showing that the desired accommodation will affirmatively enhance a disabled person’s quality of life by ameliorating the effects of the disability. Please explain the “link”:______



I certify that the information I have provided on this form is true and correct to the best of my knowledge.


Printed name of person supplying the information Signature Date


Medical title of person supplying the information Telephone Number

Ver Spec Accom Hcp Disab (5/09)1 of 2RS-10