Request For Reasonable Accommodation Form - Dc Department Of Human Services

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REQUEST FOR REASONABLE ACCOMMODATION
If you need assistance with this form or have any additional questions,
please contact: [insert name of provider’s staff contact].
Date of Request: ___________
Shelter or Housing Program: ___________________________________________
___________________________________________________________________
Name of Applicant/Client Needing Accommodation
Phone Number
___________________________________________________________________
Address
City
State
Zip Code
___________________________________________________________________
Name of Designee, if applicable
Designee’s Telephone Number
1. Describe the accommodation being requested. Use additional sheets if needed.
___________________________________________________________________
___________________________________________________________________
2. Explain why the accommodation is needed. Use additional sheets if needed.
___________________________________________________________________
___________________________________________________________________
3. Please select one of the following options:
 By signing below, I self-verify that I have, or someone in my household has, a
disability and needs the requested accommodation.
 By signing below, I authorize my shelter provider to verify that I have, or
someone in my household has, a disability and needs the requested
accommodation.
Verification Contact Information
Name: __________________________ Title: _____________________________
Agency/Institution:___________________________________________________
Fax: ___________________________ Phone: _____________________________
Client Signature: ____________________________ Date: ____________
For Shelter Staff Use Only: If a client requires a STRUCTURAL ALTERATION that your agency
cannot provide, please return this form to: Michele Williams at The Community Partnership for the
Prevention of Homelessness, 801 Pennsylvania Avenue, SE, Suite 360, Washington, DC 20003.
Phone: (202) 543-5298 Fax: (202) 543-4772
TCP Request for Reasonable Accommodation Form

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