Form S504-02 - Housing Authority Of The City Of Los Angeles Reasonable Accommodation Questionnaire
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HOUSING AUTHORITY OF THE CITY OF LOS ANGELES
REASONABLE ACCOMMODATION QUESTIONNAIRE
Print form on Legal Size Paper (8 1/2 x 14)
A person with a disability(ies) may request a change, exception or adjustment to HACLA’s rules,
policies, practices, procedures or modifications to its housing units or common areas as a reasonable
accommodation. Requesting an accommodation does not affect participation in the program. This
form is to be completed and returned to the HACLA as part of the application and annual
review process but can be requested and submitted at any time as needed.
Contact your HACLA worker if assistance is needed in completing this form.
Head of Household Name: _____________________________________ Reg # / Client # ________
Address: ________________________________________________ Phone # ________________
Other preferred contact information: ___________________________________________________
Please check the appropriate box, provide the information as necessary, sign the bottom, and submit
to the HACLA.
1. Does anyone in your household need a reasonable accommodation?
No - If No, complete number 3 below
Yes - If Yes, complete numbers 1a, 1b, 1c, 2, and 3 below
1a. Print the name of the family member requiring the accommodation _____________________
1b. Describe the accommodation needed ____________________________________________
__________________________________________________________________________
__________________________________________________________________________
1c. Is this request to rescind a negative action taken by HACLA because the family did not comply
with program requirements and the reason for not complying was due to a household
member’s disability?
No
Yes
If Yes, how did the disability prevent compliance with the rules and requirements of the
program? (Include any applicable dates) _______________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. Person who can verify the disability and the disability-related need for the accommodation, such
as (but not limited to): a licensed physician, physical therapist, psychiatrist, social worker,
caseworker, or counselor).
Name: ____________________________________________________________________
Agency (if applicable): ________________________________________________________
Address: ___________________________________________________________________
Phone number: (____) ___________________ Fax number: (____) ____________________
E-mail (if known): ____________________________________________________________
3. Signature: I certify the above information is correct:
________________________________________________ ______________
Signature of Head of Household or Cohead
Date
Please submit the completed form to the HACLA
For HACLA use only
Cal/Manager Code _________
Received by: ________________________ Date _________
Unit No.____________
Reg./Client No.____________
Notes:
Review Month ____________
S504-02 (1/24/2013)
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