Request for Reasonable Accommodation If you prefer to print and fill out this form, click the link below: Request for Reasonable Accommodation.pdf Hignell Rentals | Reasonable Accommodation Request Form STOP! In order to complete this form, you must first print out and have your medical provider complete page 2 of the: Certification of Need for Reasonable Accommodation.pdf Name* First Middle Last Address* Street Address Unit City CaliforniaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Person Needing AccommodationThe following member of my household has a physical or mental condition, disorder, or impairment that limits one (or more) major life activity and/or record of physical or mental impairment and/or is perceived by another as an individual with a physical or mental impairment:Name* First Middle Last Accommodation InformationAs a result of his/her disability, the following change or changes is/are requested so that this household member can have an equal opportunity to enjoy the premises.Check the kind of change(s) you need: A change in my residence or other part of the housing complex Change 1Description: A change in the way we communicate with you or give you information Description:Description: A change in Owner/Agent rules, policies, practices, or services Change 3Description: Other Description:Description: VerificationYou may verify that the person listed has a disability, the need for this request and possible alternatives to the specific request listed above by contacting the following medical/health provider.Provider Name Provider Provider Address Street Address Unit City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Provider PhoneProvider FaxDate and SignI (we) give The Hignell Companies permission to contact the above individual for purposes of verifying that I (or a family member) has a disability and needs the reasonable accommodation request above. I (we) understand that the information you obtain will be kept as confidential as reasonably possible while processing this request and used solely to respond to this request for an accommodation.Consent* I agree to the privacy policy.*Date* MM slash DD slash YYYY Signature*Certification of Need for Reasonable AccommodationPlease attach completed Certification of Need for Reasonable Accommodation Form* Drop files here or Select files Accepted file types: pdf, jpg, gif, png, docx, txt, Max. file size: 7 MB. *Page 2 of this form must be completed by a licensed medical provider and will be used to verify your need for accommodation.THIS SECTION IS TO BE COMPLETED BY APPLICANT/RESIDENTRELEASE: I hereby authorize the release of the requested information. I understand that signing the release is voluntary and that the information is to be used for the purposes of housing and will be kept confidential.Date* MM slash DD slash YYYY Signature* Δ
