
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: ________________________________________________________________________________________
Please return this form to:
Metro West Housing Solutions
575 Union Blvd. Suite 100 Lakewood, CO 80228
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
