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.

Verification Form

An Applicant, a Tenant or Tenant’s family member, has requested (see the other side of this form for Client/Patient’s name) a change to rules, regulations, practices or procedures.

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.”

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.”

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 Rental Unit. Owner/Agent is not required to, and will not, approve Accommodations that are a matter of convenience or preference only.

Under penalty of perjury, I attest that this individual is under my care and meets the definition of an individual with a disability, that the requested accommodation is related to the disability, and the requested accommodation is necessary to enable the person equal opportunity to use and enjoy the property.