Reasonable Accommodations Request Form - Cohhio printable pdf download

Request for Reasonable Accommodation or Modification Form

Please respond to this request in writing within 10 business days or sooner

Individual or Tenant Information

Date: _____________________________________________

Name: ______________________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

City: ___________________________________________ State: ________________________ Zip Code: ___________________________

Phone Number: ____________________________________________________________________________________________________

Email Address: _____________________________________________________________________________________________________

Landlord or Housing Provider Information

Name: ______________________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

City: ___________________________________________ State: ________________________ Zip Code: ___________________________

________________________________________ has a disability that substantially limits one or more

(Name of Individual)

major life activities as defined in the Fair Housing Act. _____________________________________’s

(Name of Individual)

disability requires the following reasonable modification and/or accommodation to use and

enjoy the housing unit:

____________________________________________________________________________________________________________

*Remember to keep copies of all documents submitted!

8/2015

Reasonable Accommodations Request Form - Cohhio