Form no. 04021HAG CS-HOU Rev. 2/2017
THE CHICKASAW NATION HOUSING DIVISION
111 Rosedale Road/P.O. Box 788/Ada, Oklahoma 74821-0788
(580) 421-8800/Fax (580) 559-0720
VERIFICATION OF DISABILITY
Name: Date:
First Middle Last Suffix
Address:
The above named individual is an applicant of the Chickasaw Nation Housing Division, and has indicated
that he/she is a disabled person. If the participant has not been determined “disabled” by the Social Security
Act, verification of disability must be verified by the attending physician. All information is confidential and will
be used only by the Chickasaw Nation Housing Division.
__________________________________ __________ Terry Davis_____________
Date Housing representative
I hereby authorize the release of this information to the Chickasaw Nation Housing Division.
Date Tenant/participant signature
*** The information below is to be completed by the attending physician. ***
I, __________________________________, do hereby verify that I am the attending physician for
_________________________________. I verify that my patient meets the following definition of
disability.
The term “disability” means – inability to engage in any substantial gainful activity by reason of any
medical 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.
Comments:
The above information is true and correct to the best of my knowledge. I understand any false information or
statements are punishable under federal law.
Physician signature: Date:
Firm name: Phone:
Address:
