060104 041518 BA RA
Head of Household Name: ________________________________
The following household member, ______________________, is requesting a reasonable accommodation for their
2. Describe the accommodation you are requesting (tell us specifically what you need):
3. Describe why this accommodation is needed and how it relates to a disability, without stating what your disability is:
4. If you are asking for an extension of time to search for housing, were you issued a Disabled and Medically Vulnerable
(DMV) voucher through the 180/220 program or the Housing Services Center (HSC)? ____ Yes ____ No____ Unknown
5. Do you have a local advocate/caseworker: ____ YES ____ NO
6. What is that person’s name: ______________________________________
7. What is their phone number: _________________________________
You will be informed of the Housing Authority’s granting, denial, or status of this request within thirty (30) days of the
receipt of this request.
Authorization to Release Information: I authorize the health care provider or social worker listed above to disclose
relevant information to the Housing Authority of the County of Santa Cruz regarding the need for a reasonable
accommodation. I understand the information the Housing Authority obtains will be kept confidential and used solely
to determine if an accommodation should be provided.
_____________________________ ______________________________ __________________
Signature of Family Member Printed Name Date
requesting accommodation
Please complete and return this form at your earliest convenience. If you have any questions regarding the completion of this form, please call our offices at (831) 454-
5955 Monday through Thursday, between 8:00 AM - 4:45 PM and Friday from 8:00 AM to 12:00 PM. Fax to 831-469-3712
8. List the name of the health care provider or social worker who can verify the disability and the need for the
accommodation requested. Return this form to the Housing Authority. The Housing Authority may contact this person
directly for verification. If you include contact information that is incomplete or incorrect, this form will be
returned to you to complete and/or correct, which will delay the processing of your request.
Name: ____________________________________ Name of Hospital, Clinic, or Office:____________________
Complete, current and accurate mailing address of the person you are asking us to contact:___________________
City: _____________________________ State: __________________ Zip Code: ________________
Phone: _________________________ Fax: ___________________________
Please Print Clearly using DARK ink. No Pastels or light colored inks.
This section for Administrative purposes only