Reasonable Accommodation and Modification Request Form

Are you, OR the person needing the accommodation disabled? *

*If you or the person your filling this request out for selected “NO” to the question above, please do not continue to fill out this form.

What is your Status? *

Currently on a WMHA Housing Program
Applicant on the waiting list

*Please DO NOT fill out this form, If you are NOT currently on a WMHA Housing Program or NOT an Applicant on any of our waiting lists

Name of The Person Requesting an Accommodations or Modification *

First

Last

Address *

and applicable) accommodation

Email (if applicable)

Phone *

I Am Requesting the Following Accomodation(s): *

Please detail the accomodation or modification

Reason for Request and Extra Notes *

Please describe the nature of the impairment and if you require any specialist equipment. A provider is entitled to obtain information that is necessary to evaluate if a requested reasonable accommodation or modification may be necessary because of a disability.

Attach Supporting Documents *

Drag & Drop Files, Choose Files to Upload

Documentation from a health provider or other person who can establish that the person has a disability and explain the nexus between the disability and the accommodation request—unless the disability is apparent to the housing provider. A requested accommodation or modification may be necessary when there is an identifiable relationship, or nexus, between the requested accommodation or modification and the individual’s disability.

Signature *

Clear Signature

Date *

*A housing provider can deny a request for a reasonable accommodation or modification if the request was not made by or on behalf of a person with a disability or if there is no disability-related need for the accommodation or modification. In addition, a request for a reasonable accommodation or modification may be denied if providing the accommodation or modification would impose an undue financial and administrative burden on the housing provider or it would fundamentally alter the nature of the housing provider’s program.