Rental Application Cover Page for Pico Robertson
This housing is offered without regard to race, color, religion, sex, gender identity and
expression, family status, national origin, marital status, ancestry, age, sexual
orientation, disability, source of income, genetic information, arbitrary characteristics, or
any other basis prohibited by law.
1. Pico Robertson has Fully Accessible Units for People with Mobility Disabilities and
People with Hearing/Vision Disabilities. Pico Robertson also has units with some
accessible features, such as no steps. If you would like to request one of these
units, please complete the Special Needs Section on page 5 of the Rental
Application. For more information about the accessible features of these units,
please contact:
Property Management Name: Cindy Wise, Mercy Housing Management Group
Title: Area Director of Operations
Phone Number: 479.459.8509 TTY (if available):*711
Email: cwise@mercyhousing.org
2. Reasonable Accommodations and Modifications will be provided upon request. A
person with a disability may ask for:
a. A change in rules (reasonable accommodation)
b. A physical change to their apartment or shared areas in the building
(reasonable modification)
c. An accessible apartment
d. Aids and services to help you communicate with us
If you or anyone in your household has a disability and needs any of these things
to live in Pico Robertson and use our services, then contact the Property
Management staff listed above to complete a form called “Request Form for
Reasonable Accommodations and Modifications”.
Page 1 of 12
MERCY
HOUSING MANAGEMENT
HOUSING APPLICATION
PROPERTY
NAME
: PICO ROBERTSON PROPERTY TELEPHONE #____________________
NOTICE: Discrimination Prohibited: The landlord will not discriminate based upon race, color, religion,
creed, national origin, sex, age, familial status, or disability. In addition, for California, our
housing programs are open to all eligible persons regardless of sexual orientation, source of
income, arbitrary characteristics, gender identity and gender expression, marital status, and
ancestry. Anyone who wishes to be admitted to the property or placed on a property’s waiting list
must complete an application. In addition to providing applicants the opportunity to complete
applications at the project site, owners may also send out and receive applications by mail. Owners
shall accommodate persons with disabilities who, as a result of their disabilities, cannot utilize the
owner’s preferred application process by providing alternative methods of taking applications.
The information you provide on this application will be treated as confidential. This application
gives no lease or rental rights. It includes both information necessary for determining your
eligibility for housing and information required for statistical purposes. If you and your household
appear to be eligible, see Tenant Selection Criteria for eligibility requirements, you will need to
submit additional information to complete the processing of this application. All information you
provide will be verified by Mercy Housing Management Group. Incomplete and/or falsified
information will cause the application to be denied and not processed.
It is the policy of Mercy-managed properties to take reasonable steps to provide meaningful access to limited
English proficient (LEP) individuals applying or residents at our apartment communities, or otherwise
encountering our property’s facilities, programs, and activities. The policy is to ensure that language will not
prevent staff from communicating effectively with LEP residents, applicants, and others to ensure safe and
orderly operations, and that limited English proficiency will not prevent applicants from participating in the
application process, or residents from accessing important programs and information, understanding rules and
regulations, and participating in meetings, events or activities.
MARKETING:
Please let us know how you heard of us:
Newspaper Ad Drove by Resident Referral Web Site Other:
For Office Use Only
Date Received:
Time Received:
Received by:
Original Updated Add-on
If updated, use original date and time stamps.
HOH Name :____________________________
Use to link multiple apps due to addt’l adults
Page 2 of 12 Eff 1/2017
Rev 4/1/2020
Please provide the following information for all persons that will live in the household
ALL AREAS MUST BE COMPLETED IN ITS ENTIRETY
Date of Application: Unit Size Needed:
Applicant Name: Applicant Name:
**Applicant SS#: **Applicant SS#:
Applicant Date of Birth: Applicant Date of Birth:
Gender*: Gender*:
Applicant Race*:__________ Ethnicity*:__________ Applicant Race*:_________ Ethnicity*:_________
*Race Options: American Indian/Alaska Native Asian African American/Black Native Hawaiian/Other
Pacific Islander White Other:
*Ethnicity Options: Hispanic/Latino or Non-Hispanic/Latino
*This information is requested by the apartment owner in order to assure the Federal Government, acting through
federal, State and local agencies that Federal Laws prohibiting discrimination against resident applicants. You
are not required to furnish this information, but are encouraged to do so. This information will not be used
in evaluating your application or to discriminate against you in any way.
**Not Required: Information from applicants who do not contend eligible immigration status, who were age 62
or older as of January 31, 2010, and who do not have a SSN, if they were receiving HUD rental assistance at
another location on January 31, 2010.
1. X
I decline to provide my Race and Ethnicity data or Gender
2. X
I decline to provide my race and ethnicity data or Gender
General Information: Please complete each field below. Answer each question as completely as possible. Enter N/A for all blank fields.
GENERAL INFORMATION
Applican
t
Applican
t
Full Name (First, Middle, Last):
Mailing Address:
City, State, Zip:
County:
Home Phone:
Work Phone:
Alternate Phone:
Email:
* Marital Status (circle one):
*You are not required to furnish this
information, but are encouraged to do so.
Single, Separated: as of___________, Married,
Divorced: as of ______________, Widowed
Single, Separated: as of___________, Married,
Divorced: as of ______________, Widowed
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Applicant Applicant
Yes No Yes No Are you a student enrolled in an institute of higher education?
Yes No Yes No Are all household members U.S. Citizens? (N/A for PRAC 202/811 & Tax Credit)
Yes No Yes No Do you anticipate a change in household composition (i.e., addition of adult household
member, household member moving out, birth or adoption of child, etc.) in the next twelve
months? Explain: ______________________________________________________
Yes No Yes No Have you or any household member disposed of, sold, donated, or gifted any assets
(including cash) for less than fair market value during the last two (2) years?
Explain: _____________________________________________________________
Yes No Yes No Have you ever been convicted of a felony or do you have a criminal history? If yes,
when and what were the circumstances?
Yes No Yes No Do you or any household member currently engage in the illegal use of drugs or your/their
behavior from this illegal use interferes with the health, safety, and right to peaceful
enjoyment of the property by other residents?
Yes No Yes No Have you been evicted in the last three years from federally-assisted housing for drug-
related criminal activity?
Yes No Yes No Have you or anyone in your household’s behavior, from abuse or pattern of abuse of
alcohol, interfered with the health, safety, and right to peaceful enjoyment by other
residents?
Yes No Yes No Has your tenancy or government assistance in a subsidized housing program ever been
terminated for fraud, non-payment of rent, or failure to comply with recertification
procedures?
Yes No Yes No Are you or anyone in your household subject to a Nationwide State lifetime Sexual
Offender’s Registration in any State?
Yes No Yes No Will this apartment be your sole place of residency?
Yes No Yes No Have you been involuntarily displaced by Government Action or Natural Disaster?
Yes No Yes No Are you a U.S. Veteran and/or in Active Duty? (Optional)
Yes No Yes No Do you have an existing Section 8 voucher?
Employment Status:
Please answer each applicable question if you are currently employed or have been employed within the last year. Enter N/A for fields that do not
apply. If you have been unemployed over the last year or have never worked, enter N/A in ALL fields.
EMPLOYMENT STATUS
Applican
t
Applican
t
Are you currently employed? If yes, where?
If employed, what is your occupation?
If employed, list current wage and frequency:
If unemployed within last year, enter last day
worked. Otherwise enter N/A.
Page 4 of 12 Eff 1/2017
Rev 4/1/2020
If unemployed, did you receive layoff notice?
Are you receiving unemployment benefits?
If unemployed, have you received any
employment income in the past 12 months? If yes,
from what source(s)?
If unemployed, why?(IDAHO only)
Otherwise, ente
r
N
/A here:
Income/Cash Benefits:
Please enter dollar amounts as estimated GROSS monthly figures for all sources of income. Please round your
figures to the nearest dollar amount. For income that does not apply, enter zero (0) in each field. Do not use
N/A in this section.
INCOME/CASH BENEFITS
Applicant Applicant
Alimony $ $
Business/Self-Employment - NET $ $
Child Support Income $ $
Employment Wage Earnings $ $
Pension Income $ $
Recurring Assistance from Others $ $
Retirement Income $ $
School Financial Assistance $ $
Social Security Benefits $ $
SSI Benefits $ $
TANF/AFDC/Monetary Public Assistance $ $
Tribal per Capita Income $ $
Unearned Income for Members Under18 $ $
Unemployment Benefits $ $
Veterans Benefits $ $
Other Income $ $
TOTAL MONTHLY INCOME $ $
Assets:
List each household member (including minors) & indicate assets held for each member in the asset table below.
*Type of assets to include: checking, savings, money market, house, land, stocks, bonds, certificates of
deposit, retirement, pension funds, insurance policies, trusts, annuities, pay cards, prepaid debit cards,
cash or other forms of capital investments. DO NOT LIST THE VALUE OF PERSONAL AUTOMOBILES
OR HOUSEHOLD FURNISHINGS. [NOTE: Each member must be listed. Enter member name in
designated field followed by “None in the Type of Asset field for those who do not have any. Otherwise,
list assets held per member & value]
HOUSEHOLD ASSETS
Household Member’s Name Type of Asset* Value ($)
Page 5 of 12 Eff 1/2017
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Household Composition:
In the table below, list the additional household members who will reside in the household not already listed on
page 1 or on an additional application. Include total number of household members in field at bottom of table
to include members who may be listed on an additional application. Please also include anyunborn
children.
HOUSEHOLD COMPOSITION
Name
(First/Last)
*Gender
M/F
Birth date Age
Grade
in
School
Do you
have full
custody?
If not,
list
percent
age of
custody
**Social Security
Number
(Required for
ALL Household
members)
*Race
(See Pg 1)
*Ethnicity
(See Pg 1)
a.
b.
c.
d.
Total # of HH Members
Include Members on page one
Household Member #: a. , b. , c. , d.
*I decline to provide my Gender, Race and Ethnicity data (Each Household Member has the option to sign
above if they’re declining to provide this information.)
**Not Required: Information from applicants who do not contend eligible immigration status, who were
age 62 or older as of January 31, 2010, and who do not have a SSN, if they were receiving HUD rental
assistance at another location on January 31, 2010.
Special Needs:
Please answer the following questions.
Are you or another household member disabled? Yes No
Do you or a household member require a special accommodation in your unit or need accessible features in the
unit (i.e. mobility, hearing/visual, or both mobility and hearing/visual)?
Yes No
This community has 24 mobility accessible units and 3 Hearing and Visual Accessible units.
Page 6 of 12 Eff 1/2017
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NOTICE OF RIGHT TO
REASONABLE ACCOMMODATION/MODIFICATION
If you have a disability and as a result of your disability you need . . .
a change in the rules or policies or how we do things that would give you an equal opportunity to use and
enjoy the housing and facilities at this housing development or take part in programs on site,
a change or repair in your apartment or a special type of apartment that would give you an equal
opportunity to use and enjoy the housing and facilities at this housing development or take part in
programs on site,
a change or repair to some other part of the housing site that would give you an equal opportunity to use
and enjoy the housing and facilities at this housing development or take part in programs on site.
If you can show that you have a disability and if your request is reasonable (*does not pose “an undue financial
or administrative burden”), we will try to make the changes you request.
We will give you an answer in 10 working days unless there is a need for verification of the request. In that case,
the response time is 15 working days unless there is a problem getting the information we need or unless you
agree to a longer time. We will let you know if we need more information or verification from you or if we would
like to talk to you about other ways to meet your needs.
If we turn down your request, we will explain the reasons and you can give us more information if you think that
will help.
If you need help filling out a REASONABLE ACCOMMODATION/MODIFICATION REQUEST FORM or if
you want to give us your request in some other way, we will help you.
You can get a REASONABLE ACCOMMODATION/MODIFICATION REQUEST FORM at the
Property office
Or by emailing 504adacoordinator@mercyhousing.org
Fax: (877)-245-7121
Or you may dial 711 for California Voice Relay Services
NOTE: All information you provide will be kept confidential and be used only to help you have an equal
opportunity to use and enjoy your housing and the common areas.
* This legal phrase means if it is not too expensive and too difficult to arrange.
Page 7 of 12 Eff 1/2017
Rev 4/1/2020
Special Needs (Optional) Continued:
If yes, select applicable accessibility needs below:
Accommodation
Wheelchair Accessible
Walker/Cane Accessible
Other Mobility Impairment Accessible
Other Vision Impairment Accessible
Other Hearing Impairment Accessible
Other Permanent Disability Accessible
Accessible Parking Space
Live-in Attendant
If attendant is needed, please give name of attendant & ordering physician:
_______________________________________________
Name of Live-in Attendant Name and Phone Number of Physician
Emergency Contact (Optional):
Please list the name and phone number of the person we should contact if we cannot reach you in the event of an emergency.
First/Last Name Phone Number
Expenses (HUD-assisted units only):
Please enter dollar amount as estimated monthly figure for all applicable expenses. For fields that do not apply,
enter zero (0). Do not use N/A in this section.
EXPENSES
Applicant Applicant
Caregiver/Caregiver Duties $ $
Child Care $ $
Companion Animal Related $ $
Dependent Care $ $
Disability Related Equipment $ $
Disability Related- Other $ $
Health Insurance Related- Other $ $
Medical Related- Other $ $
Medicare Premium $ $
Other Anticipated Medical $ $
Over-the-Counter Medication Approved by Physician $ $
Prescription Medication $ $
Page 8 of 12 Eff 1/2017
Rev 4/1/2020
Service Animal Related $ $
TOTAL MONTHLY EXPENSE $ $
Residential History: Please provide consecutive residential history. This includes the addresses for family/friends you reside with, whether or
not you pay rent, current/previous landlords & homeless shelters.
RESIDENTIAL HISTORY
Applicant Applicant
Name of CURRENT Housing Provider OR
Property:
List affiliation (circle one): Family/ Friend/ Landlord/ Owned/Shelter Family/ Friend/ Landlord/ Owned/Shelter
Address of Provider:
Address of Applicant (if different):
Provider/Property Phone Number:
Dates of Occupancy :
(mm/yy – mm/yy)
Did you pay rent? If so, how much per month?
Where you evicted or is eviction pending? If
so, why?
Applicant Applicant
Name of PREVIOUS Housing Provider OR
Property:
List affiliation (circle one): Family/ Friend/ Landlord/ Owned/Shelter Family/ Friend/ Landlord/ Owned/Shelter
Address of Provider:
Address of Applicant (if different):
Provider/Property Phone Number:
Dates of Occupancy:
(mm/yy – mm/yy)
Did you pay rent? If so, how much per month?
Were you evicted or is eviction pending? If so,
explain why:
Applicant Applicant
Name of PREVIOUS Housing Provider OR
Property
List affiliation (circle one): Family/ Friend/ Landlord/ Owned/Shelter Family/ Friend/ Landlord/ Owned/Shelter
Address of Provider:
Address of Applicant (if different):
Provider/Property Phone Number:
Dates of Occupancy:
(mm/yy – mm/yy)
Page 9 of 12 Eff 1/2017
Rev 4/1/2020
Did
y
ou pa
y
rent? If so, how much per month?
Were you evicted or is eviction pending? If so,
explain wh
y
:
Please list all states and counties you, and all household members, have resided in:
Applicant 1:
ST: _______________ ST: ________________ ST: ________________ ST: _________________ ST: _________________
COUNTY: _________ COUNTY: __________ COUNTY: ___________ COUNTY: _________ COUNTY: ___________
Applicant 2:
ST: _______________ ST: ________________ ST: ________________ ST: _________________ ST: _________________
COUNTY: _________ COUNTY: __________ COUNTY: ___________ COUNTY: _________ COUNTY: ___________
Any general information included as part of an individual household member’s records will be made accessible between departments. Other
information not routinely in a household’s records may be shared between professional staff on a need-to-know basis at the discretion of the department
or site head staff person. Information, which involves criminal acts, including use of physical force, offenses against other persons, child abuse and
neglect, etc., will be automatically reported to appropriate authorities as required by law.
I/We am/are applying for housing and state that all information provided herein is true, accurate, and complete to the best of my knowledge and belief.
Application includes pages 1 through 6 of this application. The information obtained will be used for management purposes only and will be held in
confidence.
Acknowledgment of being informed of the above:
Signature of Applicant Date
Signature of Applicant Date
ACKNOWLEDGEMENT
Any changes to your income, assets, household composition or student status from the date you signed
your application up to your move in date, must be reported to Mercy Housing Management. Failure to
do so could result in denial of your move in. If after move in we discover that changes were not reported,
Mercy Housing Management may be required to take steps that could result in eviction.
_ ______ ________
Initials Initials
PENALTIES FOR MISUSING THIS CONSENT
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to any department of the United States Government. HUD and any owner (or any
employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of
information collected based on the consent form. Use of the information collected based on this verification form
is restricted to the purposes cited above. Any person, who knowingly or willingly requests, obtains or discloses
any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor
POLICY STATEMENT & CERTIFICATION
Page 10 of 12 Eff 1/2017
Rev 4/1/2020
and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may
bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of
HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing
the social security number are contained in the **Social Security Act at 208 (a) (6), (7) and (8). Violation of
these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8) **. 6/29/2007
APPLICATION CLARIFICATION NOTES
This section is to be used only to clarify items listed on the application itself.
Item:
Item:
Item:
Item:
Item:
Item:
Page 11 of 12
Eff 1/2017
Rev 4/1/2020
Discrimination Prohibited: The landlord will not discriminate based upon race,
color, religion, creed, national origin, sex, age, familial status, or disability.
OMB Control # 2502-0581
Exp. (02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone
number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of
identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services
you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Applicant Name:
Mailing Address:
Telephone No:
Cell Phone No:
Name of Additional Contact Person or Organization:
Address:
Telephone No:
Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
E
mergency
Assist with Recertification Process
U
nable to contact you
Change in lease terms
T
ermination of rental assistance
Change in house rules
E
viction from unit
Other:
Late payment of rent
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If
issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in
resolving the issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted
by the applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person
or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal
opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally
assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act,
and the prohibition on age discrimination under the Age Discrimination Act of 1975.
Check this box if you choose not to provide the contact information.
Signature of Applicant Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
Page 12 of 12 Eff 1/2017
Rev 4/1/2020
3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation
to require housing providers
participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in
the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar
organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery
of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the
housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that
prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information, unless the
collection displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN))
which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
Page 1 of 3Form: Supplemental and Optional Contact Information for Applicants
(REV. 2020.01.21)
APPENDIX 8
SUPPLEMENTAL AND OPTIONAL CONTACT INFORMATION FOR
APPLICANTS
Property Name:
THIS FORM IS TO BE PROVIDED TO EACH APPLICANT FOR
HOUSING
Instructions: Optional Contact Person or Organization:
You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a
family member, friend, or social, health, advocacy, or other organization.
This contact information is for the purpose of identifying a person or
organization that may be able to help in resolving any issues that may arise
during your tenancy or to assist in providing any special care or services
you may require. You may update, remove, or change the information you
provide on this form at any time. You are not required to provide this
contact information, but if you choose to do so, please include the relevant
information on this form.
Applicant Name:
Mailing Address:
Telephone Number:
TTY or VP Number:
Cell Phone Number:
Email Address (if Applicable):
Pico Robertson Senior Community
Page 2 of 3Form: Supplemental and Optional Contact Information for Applicants
(REV. 2020.01.21)
Name of Additional Contact Person or Organization:
Address:
Telephone Number:
TTY or VP Number:
Cell Phone Number:
Email Address (if Applicable):
Relationship to Applicant:
Reasons that you approve us to contact the Additional Contact
Person or Organization: (Check all that apply)
Emergency
Unable to contact you
Proposed termination of rental assistance
Proposed eviction
Late rent payment
Help with Recertification Change
Change in lease terms
Change in policies or procedures
Other (please specify):
Commitment of Owner
If you are approved for housing, this information will be kept as part of your
tenant file. If issues arise during your tenancy or if you require any services
Page 3 of 3Form: Supplemental and Optional Contact Information for Applicants
(REV. 2020.01.21)
or special care, we may contact the person or organization you listed to
assist in resolving the issues or in providing any services or special care to
you.
Confidentiality Statement
The information on this form is confidential and will not be disclosed to
anyone except as permitted by you, the applicant, or applicable law.
Legal Notification
Section 644 of the Housing and Community Development Act of 1992
(Public Law 102-550, approved October 28, 1992) requires each applicant
for federally assisted housing to be offered the option of providing
information regarding an additional contact person or organization. By
accepting the applicant’s application, the housing provider agrees to
comply with the non-discrimination and equal opportunity requirements of
24 CFR section 5.105, including the prohibitions on discrimination in
admission to or participation in federally assisted housing programs on the
basis of race, color, religion, national origin, sex, disability, and familial
status under the Fair Housing Act, and the prohibition on age discrimination
under the Age Discrimination Act of 1975.
Option Not to Provide a Supplemental Contact Person:
Check this box if you choose not to provide the contact
information.
Signature of Applicant:
Date:
Signature:
See Tenant Handbook Section 3.17 for More Information
Form: Notice to Right to Reasonable Accommodations and Effective Auxiliary
Aids (REV. 2020.01.21) Page 1 of 6
APPENDIX 2
NOTICE OF RIGHT TO REASONABLE ACCOMMODATIONS AND
AUXILIARY AIDS PURSUANT TO EFFECTIVE COMMUNICATION
POLICY AT
[Insert property name in fillable area]
WHAT ACCOMMODATIONS AND AUXILIARY AIDS CAN I ASK FOR?
You or anyone in your household can ask for:
1. An accommodation if you have a disability and need a change or
exception to our standard rules, eligibility criteria, policies, or
practices, so that you are able to use and enjoy a unit in our
property, public and common use areas, or participate in, or
benefit from, a program, service or activity.
2. An accessibility alteration (physical changes) to your unit or a
common area.
3. Auxiliary Aids and Services necessary to ensure effective
communication between us. This can include providing
information in alternative formats or for example, Braille, American
Sign Language (ASL) interpreters, large print documents.
We will pay all reasonable costs for Reasonable Accommodations and
Auxiliary Aids necessary to ensure effective communication between us.
Pico Robertson Senior Community
Form: Notice to Right to Reasonable Accommodations and Effective Auxiliary
Aids (REV. 2020.01.21) Page 2 of 6
WHO WILL BE ABLE TO SEE INFORMATION ABOUT MY REQUEST?
All information you provide is confidential. Information about your request
will only be shared with people who need to decide on or carry out the
request, or if required by law.
WHAT ARE REASONABLE ACCOMMODATIONS?
Reasonable Accommodations are changes, modifications, exceptions,
alterations, or adaptations in our rules, policies, practices, programs,
services, activities, or facilities that may be necessary to (1) provide an
Individual with a Disability an equal opportunity to use and enjoy a dwelling,
including public and common use areas of a development, (2) participate
in, or benefit from, a program (housing or non-housing), service or activity;
or (3) avoid discrimination against a person with a disability. A Reasonable
Accommodation includes any physical or structural change to a Unit or a
public or common use area.
Examples are:
1. Allowing an assistance animal in a “no-pets” building;
2. Allowing payment of rent on a date other than the first of the month if
necessary due to the date the tenant receives disability income;
3. Granting a reserved parking space closer to the person’s unit;
4. Providing additional accessible or assigned parking where required
accessible parking is not sufficient to meet the needs of tenants and
applicants;
Form: Notice to Right to Reasonable Accommodations and Effective Auxiliary
Aids (REV. 2020.01.21) Page 3 of 6
5. Accepting references from professional caregivers and others when
landlord references are not available for a person moving from a
nursing home or other places that serve Individuals with disabilities;
6. Installing a wheelchair ramp;
7. Installing grab bars in the shower or bathroom;
8. Installing a roll-in shower;
9. Installing visual alerting systems and flashing lights for persons who
are deaf or hard of hearing;
10. Adjusting counter heights for individuals who use wheelchairs;
11. Transferring a tenant in a non-elevator building who has difficulties
walking up or down stairs to a ground floor unit with no or very few
stairs; and
12. Requesting that [PROPERTY NAME TO BE COMPLETED BY
OWNER]
notify another individual in addition to the tenant or applicant when
any concerns arise. See Appendix 8, Supplemental and Optional
Contact Information for Applicants.
WHAT ARE AUXILIARY AIDS?
Auxiliary Aids are aids, services, or devices that enable persons with vision,
hearing, manual, or speech impairments to have an equal opportunity to
participate in, or enjoy the benefits of, programs, services, or activities,
including housing and other programs, services, and activities.
Examples are:
1. Giving you documents in large print, Braille, on cassettes or CDs, or
electronically; or reading documents to you.
Pico Robertson Senior Community
Form: Notice to Right to Reasonable Accommodations and Effective Auxiliary
Aids (REV. 2020.01.21) Page 4 of 6
2. Providing a sign language interpreter or using a video relay service.
3. Notetakers; real-time computer-aided transcription services;
exchange of written notes.
4. Providing audio description, or audio recordings.
5. Providing closed captioned video.
These are just examples. You can ask for other Reasonable
Accommodations and Auxiliary Aids you need because of your disability.
WHEN CAN I ASK FOR A REASONABLE ACCOMMODATION OR
AUXILIARY AID?
You can ask at any time. This includes when you apply to rent, while you
live here, and even when you are moving out. You may designate a third
person or agent who may act or speak for you regarding your request.
HOW DO I ASK FOR REASONABLE ACCOMMODATIONS OR
AUXILIARY AIDS?
You can ask a Property Manager, or fill out a Request Form. We can help
you fill out the form. Ask us if you need to communicate with us in a
particular way due to your disability.
WHAT KIND OF INFORMATION DO I NEED TO GIVE YOU?
You need to tell us what you need and how it is related to your disability.
WHAT HAPPENS AFTER I ASK?
We will respond to you as quickly as possible.
Form: Notice to Right to Reasonable Accommodations and Effective Auxiliary
Aids (REV. 2020.01.21) Page 5 of 6
We may ask you for more information.
Your need for Reasonable Accommodations or Auxiliary Aids may be
obvious or already known. For example, if you use a wheelchair it may be
obvious you need accessible parking. If your need for the accommodation
or auxiliary aid is obvious or already known, we will not ask for any
additional information. If your need for an accommodation or auxiliary aid
is not obvious, we may ask you to provide more information, which may
include information from someone else who knows about your disability
needs. We will only seek limited information that is necessary to
understand the disability-related need for your accommodation or auxiliary
aid. We do not need to receive full medical records or to know unrelated
information about the nature or severity of any disabilities. Any information
we do receive will be kept confidential.
If we ask you for information from someone else, we will give you an
Additional Information Form. An Additional Information Form may be
needed if your disability or your need for a Reasonable Accommodation or
Auxiliary Aid is not obvious or already known.
You can choose how to get the additional information:
1. You can sign the Part 2 of the Additional Information Form and return
it to the office. We will then send the form to the person you listed
and ask them to fill it out and return it to us.
OR:
2. You can sign the Part 2 of the Additional Information Form and give it
to the person you want to fill out the rest of the form. You can return
Form: Notice to Right to Reasonable Accommodations and Effective Auxiliary
Aids (REV. 2020.01.21) Page 6 of 6
it to us when it is complete. When the Additional Information
Form is returned, we will tell you if we need more information.
We may need to talk with you more. Again, ask us if you need to
communicate with us in a particular way due to your disability.
We will let you know our final decision in writing. If we deny your request,
you can ask for a meeting to discuss it. Your position on the wait list or
your tenancy will not be affected because you make a request.
HOW LONG WILL IT TAKE TO GET AN ANSWER?
Usually, we will respond within 5 business days of getting the request. If it
is urgent, we will try to respond sooner. If additional information is needed,
or if we need to meet or talk with you about options, we will give you an
answer as soon as we can, but no later than within 30 days.
For questions or help with your request, please contact:
(Owner/property manager to complete)
Name:
Title:
Address:
Office Phone:
TTY Number:
Email (if available):
See Tenant Handbook Section 3.14 for More Information
Cindy Wise
Area Director of Operations
1500 S Grand Ave, Ste 100, Los Angeles, CA 90015
479-459-8509
*711
cwise@mercyhousing.org
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