Form S504 01C – Fill Out and Use This PDF

HOUSING AUTHORITY OF THE CITY OF LOS ANGELES

CERTIFICATION OF NEED FOR REASONABLE ACCOMMODATION

To allow equal access to its programs, HACLA may grant a reasonable accommodation to a family applying for or residing in subsidized housing if there is a clear connection (nexus) between: 1) a requested accommodation, 2) a family member’s disability and 3) a HACLA program. We ask your cooperation in providing the information requested below. This information will be used only in regard to the requested accommodation. Please do not return this form to the person named above – the form must be sent directly to the Housing Authority. A self-addressed envelope is enclosed for your convenience in returning the form. Thank you for your assistance.

If you have any questions, please contact _______________________________ at (______)______________

Person requesting the accommodation: ____________________________________________________

I authorize you to: (1) Complete this certification of need for reasonable accommodations; and (2) Release information directly to the Housing Authority on this form or to further document need for the accommodation.

Signature __________________________________________________________ Date ________________

(A parent/guardian shall sign for a minor. A requestor’s conservator may sign. Adult requestors shall sign)

REQUESTED ACCOMMODATION:________________________________________________________________

________________________________________________________________________________________________

TO BE COMPLETED BY THE HEALTH CARE PROVIDER

A. CERTIFICATION OF DISABILITY

For the purposes of REASONABLE ACCOMMODATION, an individual has a disability if he or she 1) has a physical or mental impairment that substantially limits one or more major life activities, 2) has a record of such an impairment, or 3) is regarded as having such an impairment.

IF YES Circle the major life activity(ies) affected: Self-care, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working; or other (Please specify)__________________________

_______________________________________________________________________________________

B. CONNECTION (NEXUS) - DISABILTY AND REQUESTED ACCOMMODATION

a)HOW is the accommodation linked to the person’s disability?________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

b)HOW does this accommodation allow equal benefit from HACLA’s program?__________________

___________________________________________________________________________________

___________________________________________________________________________________

c)WHAT would be an equally effective alternative accommodation(s)?________________________________

___________________________________________________________________________________________

Please attach an additional page if more space is needed.

C.CERTIFICATION

I certify that the information above is accurate and true.*

Signature _________________________________________ Title/Position ___________________________

Print Name _____________________________________ Date __________ Phone No. _________________

License Number: _________________________ AND/OR Agency Name ___________________________

Either a license number and/or an agency name must be provided for this form to be accepted. Return this form to the Housing Authority only. Do not give or mail this form to any other agency, entity or person.

*WARNING: 18 U.S.C. 1001 provides that whoever knowingly and willingly makes or uses a document or writing containing a false, fictitious, or fraudulent statement or entry in any manner within the jurisdiction of any department or

agency of the United States shall be fined or imprisoned for not more than five years or both.

S504-01C (6/06)