
Verification of Disability/Handicapped Status
______________________________________________________
Applicant/Participant
________-_____________-_______
Social Security Number
TO WHOM IT MAY CONCERN:
The applicant/participant is applying for housing assistance subsidized through the Department of Housing and Urban Development. Federal regulations require that all income, expenses, preferences and other information related to eligibility must be third-party verified. Please complete this form as it applies to the above-named family member who is claiming preference. Be assured that your reply will be kept confidential. Please provide the requested information within the next ten days. If you have any questions, please contact:
________________________________________ at ___________________________________
Housing Specialist Telephone Number
RELEASE OF INFORMATION
I hereby authorize the release of the information requested below:
_______________________________________________ _______________________
Signature of Head of Household Date
_______________________________________________ _______________________
Signature of Family Member (if adult) Date
This is to certify that, in my opinion, ____________________________________________ is ☐ or is not ☐ (choose one) disabled/handicapped to such extent that one of the following applies to their condition:
☐ a) The person has a disability as defined in Section 223 of the Social Security Act of (42 U.S.C. 423);
☐ b) The person has a developmental disability as described by Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C. 6001(7); or
☐ c) The person has a physical, mental or emotional impairment that:
a. Is expected to be of long-continued and indefinite duration;
b. Substantially impedes their ability to live independently, and
c. Is of such nature that ability to live independently could be improved by more suitable housing conditions.
Disability began on/about __________________________________. (Housing Specialist may not verify this information)
Signature of Evaluator: _______________________________ Print Name of Evaluator: __________________________
Street Address: ____________________________ City: _________________ State: _____ Zip Code: ________________
Telephone: _____________________________________________ Date: ______________________________________
WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE WILLFUL, FALSE STATEMENTS OF MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE U.S. AS TO ANY MATTER WITHIN ITS JURISDICTION.
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
