LIVE-IN AIDE REASONABLE ACCOMMODATION PACKET
Metro West Housing Solutions (MWHS) must grant approval before a Live-in Aide may reside in a MWHS
assisted unit. Each form in this packet must be complete, and the following documents must be submitted to
your Housing Specialist before a Live-in Aide can be approved:
• Live-in Aide’s state issued photo ID
• Live-in Aide’s social security card
• Live-in Aide’s birth certificate
• Live-in Aide’s Declaration of Section 214 Status Form
REQUEST FOR REASONABLE ACCOMMODATION
(to be completed by tenant)
Person Requesting Reasonable Accommodation: __________________________________________________
Request is made on behalf of: ☐ Self or ☐ Other Person: ___________________________________________
Phone Number (or other contact information): ___________________________________________________
Address: __________________________________________________________________________________
Section 504 of the Rehabilitation Act and the Fair Housing Amendments Act defines a “disability” as a physical or mental impairment which substantially limits one or more of a person’s major life activities, a record of having such impairment or being regarded as having such an impairment.
1. Based on the above definition, I consider myself to be an individual with a disability. ☐ Yes ☐ No
2. As a result of my disability, I am requesting a reasonable accommodation in order to have an equal
opportunity to participate in, or benefit from, MWHS’s housing programs. ☐ Yes ☐ No
3. As a result of my disability, I am requesting the following accommodation in order to have an equal
opportunity to participate in, or benefit from, MWHS’s housing programs: _______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. As a result of my disability, the above accommodation is necessary because: ______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
5. Verification Information: Please provide MWHS with the contact information of a knowledgeable
professional who can verify the disability and the need for the requested reasonable accommodation:
Name: ________________________________________ Title: _______________________________________________
Address: ___________________________________________________________________________________________
Phone: ________________________________________ Fax: ________________________________________________
Authorization to Release Information: I authorize the individual/care provider listed above to disclose relevant information to MWHS verifying that I have a disability and need the accommodation I have requested. I understand that the information MWHS obtains will be kept confidential and used solely to determine if an accommodation should be provided.
Signature: _________________________________________________ Date: ___________________________________
Print Name: ________________________________________________________________________________________
LIVE-IN AIDE REQUEST VERIFICATION
TO BE COMPLETED BY HEAD OF HOUSEHOLD
Date: _________________
HEALTHCARE PROVIDER’S NAME: ____________________________________
HEALTHCARE PROVIDER’S ADDRESS: ___________________________________________________________
HOUSEHOLD MEMBER’S NAME: ___ _____ __________________
HOUSEHOLD MEMBER’S ADDRESS: ________________________
HOUSING SPECIALIST: ________________________
HOUSING SPECIALIST EMAIL: _________________________________________________________________
HOUSEHOLD MEMBER RELEASE
I authorize the healthcare provider listed above to disclose relevant information to MWHS verifying that I have a disability and need the accommodation I have requested. I understand that the information that MWHS obtains will be kept confidential and used solely to determine if an accommodation should be provided.
Head of Household Signature: _________________________________________________ Date: __________________________________
TO BE COMPLETED BY HEALTHCARE PROVIDER
Definition of ‘disabled’: Under federal law, an individual is disabled if he/she has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment.
1. Is the household member disabled, as defined above?
☐ Yes ☐ No
2. In your professional opinion, does the household member need the services of a live-in aide in order to
have the same opportunity that a nondisabled individual has to use and enjoy the unit?
☐ Yes ☐ No
Healthcare Provider’s Name: __________________________________________________________________
Healthcare Provider’s Title: ___________________________________________________________________
Healthcare Provider’s Signature: _____________________________________ Date: ____________________
LIVE-IN AIDE DECLARATION
TO BE COMPLETED BY HEAD OF HOUSEHOLD
As Head of Household, I understand that the following applies to both my Live-in Aide and me:
- The Live-in Aide is not required to pay rent or utilities.
- The Live-in Aide is not a responsible party to the lease.
- If the Live-in Aide moves out, I must report it to my housing agency within ten days.
- I understand that if the Live-in Aide has any changes in their family composition, I must report it within
ten days. No other members will live in the unit without prior approval. - I cannot allow anyone else to be a Live-in Aide without prior approval of the housing agency.
Head of Household Signature: _____________________________________ Date: ____________________
TO BE COMPLETED BY LIVE-IN AIDE
As the approved Live-in Aide for ___________________________________ (Head of Household name,) I confirm that the following statements are true and accurate:
- I would not be living in the unit except to provide the needed supportive services.
- This unit will be my only residence and address. I do not reside at any other address.
- I understand that I can be removed from the household as a Live-in Aide at any time at the request of the Head of Household and must vacate the unit immediately if asked.
- I will not sign the lease; I will only be listed as someone living in the unit.
- If the Head of Household or person needing the care is no longer eligible for the voucher, I understand that I have no rights to the voucher.
Live-in Aide Signature: _____________________________________ Date: ____________________
DECLARATION OF SECTION 214 STATUS
Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read the Declaration statement carefully and sign and return to the PHA’s main office. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.
I, _____________________________________________ certify, under penalty of perjury 1/, that, to the best of my knowledge, I am lawfully within the United States because (please check the appropriate box):
☐ I am a citizen by birth, a naturalized citizen or a national of the United States; or
☐ I have eligible immigration status, and I am 62 years of age or older. Attach evidence of proof of age 2/; or
☐ I have eligible immigration status as checked below (see reverse side of this form for explanations.) Attach INS document(s) evidencing eligible immigration status and signed verification consent form.
☐ Immigrant status under §§101(a)(15) or §§101(a)(20) of the Immigration and Nationality Act (INA) 3/; or
☐ Permanent residence under §249 of the INA 4/; or
☐ Refugee, asylum, or conditional entry status under §§207, 208 or 203 of the INA 5/; or
☐ Parole status under §§212(d)(5) of the INA 6/; or
☐ Threat to life or freedom under §243(h) of the INA 7/; or
☐ Amnesty under §245A of the INA 8/.
Signature of Family Member: _________________________________________________ Date: __________________________________
☐ Check box on left if signature is of adult residing in the unit who is responsible for child named on statement above.
PHA: Enter INS/SAVE Primary Verification #: ________________________ Date: _________________________
1/ Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five years, or both.
The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following categories:
2/ Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required.
3/ Immigrant status under §§101(a) (15) or 101(a) (20) of the INA. A noncitizen lawfully admitted for permanent residence, as defined by §101(1) (20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by §101(a) (15) of the INA (8 U.S.C. 1101(a) (20) and 1101(a) (15), respectively [immigrant status]. This category includes a noncitizen admitted under §§210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status.
4/ Permanent resident under §249 of the INA. A noncitizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under §249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249].
5/ Refugee, asylum, or conditional entry status under §§207, 208 or 203 of the INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under §208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under §203(a)(7) of the INA (U.S.C. 1153(a)(7)) before April 1, 1980, because of persecution or fear of persecution on account of race, religion or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status].
6/ Parole status under §212(d) (5) of the INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under §212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status].
7/ Threat to life or freedom under §243(h) of the INA. A noncitizen who is lawfully present in the U.S. as a result of the Attorney General’s withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) [Threat to life or freedom].
8/ Amnesty under §245A of the INA. A noncitizen who is lawfully admitted for temporary or permanent residence under §245A of the INA (8 U.S.C. 1255a) [Amnesty granted under INA 245A].
Instructions to Public Housing Authority: Following verification of status claimed by persons declaring eligible immigration status (other than for noncitizens age 62 or older and receiving assistance on June 19, 1995,) the PHA must enter INS/SAVE Verification Number and date that it was obtained. A PHA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first name, middle initial(s), and last name. Place an “X” or “✓” in the appropriate boxes. Sign and date at bottom of page. Place an “X” or “✓” in the box below the signature if the signature is by the adult residing in the unit who is responsible for the child.
ALTERNATIVE FORMATS OF THIS DOCUMENT ARE AVAILABLE UPON REQUEST.
575 Union Blvd Suite 100, Lakewood, Colorado 80228 ● Phone 303-987-7580 ● TTY 711 ● www.mwhs.org
