Certification Of Disability Form printable pdf download

CERTIFICATION OF DISABILITY

To: ___________________________

Re: __________________________

___________________________

SS#:_________________________

___________________________

The above-named individual is applying for participation in a federally-assisted housing program

operated by the Housing Authority. To determine the applicant’s eligibility, we must verify that

he/she is disabled as defined by the U.S. Department of Housing and Urban Development (HUD).

HUD regulations define disability as follows.

A. Inability to engage in any substantial gainful activity by reason of any medically

determinable physical or mental impairment which can be expected to result in death, or

which has lasted or can be expected to last for a continuous period of not less than 12

months, or in the case of an individual who has attained the age of 55 and is blind and

unable by reason of such blindness to engage in substantial, gainful activity requiring

skills or ability comparable to those of any gainful activity in which he/she has previously

engaged with some regularity and over a substantial period of time.

B. Severe chronic disability that:

a. is attributable to a mental or physical impairment or combination of mental and

physical impairments;

b. is manifested before the person attains age 22;

c. is likely to continue indefinitely;

d. results in substantial functional limitations in three or more of the following areas

of major life activity: (1) self-care, (2) receptive and responsive language, (3)

learning, (4) mobility, (5) self-direction, (6) capacity for independent living, (7)

economic self-sufficiency;

e. reflects the person’s need for a combination and sequence of special

interdisciplinary, or generic care, treatment, or other services which are of

lifelong or extended duration and are individually planned and coordinated.

C. A person with a physical or mental impairment that:

a. is expected to be of a long-continued and indefinite duration,

b. substantially impedes his/her ability to live independently, and

c. is of such a nature that such ability could be improved by more suitable housing

conditions.

D. Federal Law now states that a person is not considered disabled for eligibility purposes

solely on the basis of any drug or alcohol dependence. Individuals whose alcohol or

drug addiction is a material factor to their disability are excluded from the definition.

Individuals are considered disabled if the disabling mental and physical limitations would

persist if the drug or alcohol abuse discontinued.

Housing Authority Representative__________________________ Date___________________

I hereby authorize the release of any information pertaining to this request, and will appreciate it

if you will complete and return to the Housing Authority the following certification.

Applicant’s Signature:

___________________________________________Date_________________

Date________________________

Certification of Disability

Client Name: ____________________________ ( ) does ( ) does not meet the above definition

of a person with a disability

Applicable definition(s): ( ) A ( ) B ( ) C

Estimated length of disability period: ________________________________________________

Certified By: _____________________________ Date: ___________________

Office: ____________________________Title:__________________________

Address: __________________________Telephone:____________________

Warning: Section 1001 of the Title 13 of the U.S. Code makes it a criminal offense to make

willful false statements or misrepresentations to any Department or Agency of the United

States as to any matter within its jurisdiction.

Please Return or Fax This Form To: Bloomington Housing Authority 1007N. Summit St.

Bloomington, IN 47404

Fax to: (812) 339-7177

Certification Of Disability Form

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