Form S504 01C PDF Details

The S504 01C application form is used to apply for a Canadian citizenship. This form can be used by anyone who is 18 years of age or older and meets the requirements for Canadian citizenship. In order to complete this form, you will need to provide information about your identity, your family history, and other important documents. The processing time for this form can take up to six months, so it is important to submit all of the required documentation with your application. For more information on how to complete this form, please visit our website. Thank you for choosing Canada!

QuestionAnswer
Form NameForm S504 01C
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesies, S504-01C, housing authorizty of los angeles certification of need for reasonable accomodation s504 03, LOS

Form Preview Example

HOUSING AUTHORITY OF THE CITY OF LOS ANGELES

CERTIFICATION OF NEED FOR REASONABLE ACCOMMODATION

TO:

Date _____________

Cal/Manager Code _____________

Unit No._____________

Reg./Client No._____________

Review Month _____________

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 (______)______________

PLEASE RETURN DIRECTLY

TO THE HOUSING

AUTHORITY NO LATER THAN

Return To: HACLA Attn:

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.

Does the above named individual meet this definition of disability?

YES

or

NO

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

IF NO

IS THERE A CONNECTION (NEXUS) between the

accommodation requested above and the disability?

IF

YES

Check this box. Go to SECTION C.

Check this box. Answer a, b & c below:

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)

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Pay close attention while filling out this document. Make sure that every single blank is filled out correctly.

1. It's vital to complete the false properly, therefore be attentive when filling out the sections including these blank fields:

The best way to complete S504-01C portion 1

2. The subsequent step is usually to submit all of the following blanks: Person requesting the, Signature Date, A parentguardian shall sign for a, REQUESTED ACCOMMODATION, TO BE COMPLETED BY THE HEALTH CARE, A CERTIFICATION OF DISABILITY, For the purposes of REASONABLE, Does the above named individual, B CONNECTION NEXUS DISABILTY AND, IS THERE A CONNECTION NEXUS, IF NO Check this box Go to SECTION, IF YES Check this box Answer a b, and a HOW is the accommodation linked.

IS THERE A CONNECTION NEXUS, TO BE COMPLETED BY THE HEALTH CARE, and B CONNECTION NEXUS DISABILTY AND in S504-01C

It is possible to make a mistake while filling in your IS THERE A CONNECTION NEXUS, and so make sure to go through it again prior to deciding to send it in.

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