Eden, Inc. Housing Application Form Page 5
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7SECTION 202/8, SECTION 202 PAC,
U.S. Department of Housing
OMB Approval No. 2502-0204
SECTION 202 PRAC, AND
and Urban Development
(exp.03/31/2014)
SECTION 811 PRAC
Office of Housing Federal
Housing Commissioner
VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION OR QUALIFICATION
FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY FOR USE WITH SECTION
202/8, SECTION 202 PAC, Section 202 PRAC, AND SECTION 811 PRAC
DATE: __________________________________
TO:
___________________________________
___________________________________
FROM:
EDEN, INC, 7812 MADISON CLEVELAND OH 44102
ATTN:
AMBER SMITH
RETURN THIS VERIFICATION TO THE PERSON LISTED ABOVE
SUBJECT: Verification of Disability
NAME:___________________________________________________________
ADDRESS________________________________________________________
This person has applied for housing assistance under a program of the U.S. Department of Housing and Urban
Development (HUD). HUD requires the housing owner to verify all information that is used in determining this
person’s eligibility or level of benefits.
We ask your cooperation in providing the following information and returning it to the person listed at the top of the
page. Your prompt return of this information will help to ensure timely processing of the application for assistance.
Enclosed is a self-addressed, stamped envelope for this purpose. The applicant/tenant has consented to this release
of information as shown above.
===================================================================
INFORMATION BEING REQUESTED
For each numbered item below, mark an “X” in the applicable box that accurately describes the person listed above.
1.
YES___NO
Has a physical, mental, or emotional impairment that is expected to
be of long-continued and indefinite duration, substantially impedes
his or her ability to live independently, and is of a nature that such
ability could be improved by more suitable housing conditions.
2. ___YES ___NO
Is a person with a developmental disability, as defined in Section 102(7) of
the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C.
6001(8)), i.e., a person with a severe chronic disability that:
a
. Is attributable to a mental or physical impairment or combination of mental and
physical impairments;
b. Is manifested before the person attains age 22;
c. Is likely to continue indefinitely;
d. Results in substantial functional limitation in three or more of the following areas
of major life activity;
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