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FORM #53 - Request for Reasonable Accomodation

NOTICE: Under law, Tenant(s) have the right to request a change in rules, regulations, practices, or procedures if Tenant(s) have a handicap and the requested change will better enable Tenant(s) to use and enjoy the property. Owner/Agent may require Tenant(s) both to document the existence of the disability and to obtain verification from a qualified person (for example; a counselor, doctor, social worker, or rehabilitation center) that the accommodation is related to the disability and would give equal opportunity to use and enjoy the property. If this request follows a notice of noncompliance with the terms of a rental agreement, Owner/Agent may also ask for documentation to support the claim that the accommodation will better enable compliance with the agreement. To request such an accommodation, Tenant(s) must fill out the form below and return it to Owner/Agent.

Name: ____________________________________________

Address: ____________________________________________

City: ___________________________, Oregon Zip: ____________

We are requesting a modification of rules, regulations, practices, or procedures for ____________________________________________ (name of person for whom accommodation is requested).

The change we are requesting is (describe what it is you want): ____________________________________________

The name and address of the qualified person (such as a doctor, health care provider, or social worker) who can provide the necessary verification is:

Name: ____________________________________________

Address: ____________________________________________

City: _______________________ State: _______ Zip: __________

Phone: ______________________ Fax: _________________________

I authorize Owner/Agent to contact the above person. I understand that Owner/Agent will be asking for the verifications found on the reverse of this form. I authorize the above named qualified person to release such information directly to Owner/Agent.

______________________________________ Date: ________________

FROM: ________________________________



TO: ________________________________

Qualified Health Care Provider



An applicant, a tenant or tenant's family member, __________________________, has requested (see the other side of this form) a change to rules, regulations, practices or procedures.

Owner/Agent is required under Federal Fair Housing law to make reasonable accommodations when such accommodation will give someone who is disabled an equal opportunity to use and enjoy the housing. Owner/Agent is not required to, and will not, approve accommodations that are a matter of convenience or preference only.

Under federal law, someone is handicapped or disabled if they suffer "a physical or mental impairment which substantially limits one or more major life activities," or if they have "a record of such an impairment," or are "regarded as having such an impairment." Not included in the definition is someone who is a current illegal user of controlled substances.

A physical or mental impairment means "(1) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: Neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive; digestive; genitor-urinary; hemic and lymphatic; skin; and endocrine; or (2) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities." Such an 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 (other than addiction caused by current, illegal use of a controlled substance) and alcoholism."

The term "major life activities" means "functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working."

In order to determine if the Tenant and the accommodation fit within the terms of the law, please verify the following:

It is my professional opinion that:

The person listed above meets the definition of an individual with a disability.

The requested accommodation is related to the disability.

The requested accommodation is necessary to enable the person equal opportunity to use and enjoy the property.

Signed: _______________________________________

Printed Name:__________________________________

Professional Title: ___________________________

Date: _________________________________

Organization: ________________________________



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1462 Commercial St. NE, Salem, OR 97301
Phone: 503-364-5468 | Fax: 503-585-8119

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