REASONABLE ACCOMMODATION
VERIFICATION FORM
Date: ____________________
Name and Address of Verification Source:
_______________________________________________________________
_______________________________________________________________
Head of Household: ______________________________________________
Name of the household member needing accommodation:
_______________________________________________________________
The individual listed above has identified him or herself as having a disability
and has asked for an accommodation from this agency to meet certain needs
dictated by the disability.
The Homeless Service Provider grants reasonable accommodation requests
based in part by verification of need from a qualified professional who has
direct experience with an individual’s disability. Individuals qualified to
complete this form are counselors, social workers, physicians, psychiatrists,
professionals at non-medical service agencies, peer support groups, or a
reliable third party who is in a position to know about the client’s disability.
DC Homeless Service providers are required by law to provide reasonable
accommodations to applicants/residents with disabilities that will provide them
with equal opportunity to use and enjoy our programs, their unit and/or
common areas. Homeless Service programs do not provide accommodations
when the request is a matter of convenience or preference only.
You have been authorized to release information to us regarding the need for
an accommodation/modification.
_______________________ has requested that ________________________
(Client Name)
(Shelter/Housing Program)
in Washington, D.C. provide the following accommodation(s):
_______________________________________________________________
_______________________________________________________________
TCP Reasonable Accommodation Verification Form