Reasonable Accommodation Request Form

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Reasonable Accommodation Request Form
Date: ___________________
Head of Household Name: _____________________________________ Phone: ________________
Address: __________________________________________________________ Zip: _____________
PO Box or Street
City/Town
The following member of my household has a disability: _____________________________________
Please let us know how the accommodation will help you to take part in our program and help you to meet other
requirements of our program. Please attach a separate sheet if you need more space.
• Do not give us medical information about your disability
• Do not give us the name of your disability or the nature or extent of your disability
Please provide the following reasonable accommodation: _________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I need this reasonable accommodation because: ____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
4/2015
New Hampshire Housing Finance Authority
32 Constitution Drive Bedford, NH 03110 Mailing Address: P.O. Box 5087 Manchester, NH 03108 (603) 472-8623 TDD: (603) 472-2089
Assisted Housing Division: (800) 439-7247 Fax: (603) 472-8729

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