VERIFICATION OF NEED FOR REASONABLE ACCOMMODATION
(to be completed by knowledgeable professional)
Person Requesting Reasonable Accommodation: _________________________________________________________
Date of Birth: __________________ Last Four of SSN: XXX-XX-_________ Today’s Date: __________________________
The individual listed above has identified themself as being a person with a disability and has requested an accommodation from Metro West Housing Solutions (MWHS) in order to have an equal opportunity to benefit from its housing programs. An accommodation must be reasonable, and there must be an identifiable relationship between the requested accommodation and the individual’s disability or the symptoms of the disability. You have been authorized to release information to us regarding the need for an accommodation.
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. Does the individual have a disability as defined above? ☐ Yes ☐ No
2. Describe how the requested reasonable accommodation listed on the attached Request for Reasonable
Accommodation form is necessary to afford this individual the opportunity to access housing, maintain housing
or for full use and enjoyment of housing in order to have an equal opportunity to participate in, or benefit from,
MWHS’s housing program.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
3. Is the requested accommodation directly related to the individual’s disability? ☐ Yes ☐ No
Printed Name: __________________________________________ Title: ______________________________________
Address: ___________________________________________________________________________________________
Phone: ________________________________________________ Fax: _______________________________________
Signature: _____________________________________________________ Date: ______________________________
Note: please attach additional pages if necessary to provide any additional information that may assist us in reaching a decision.
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
