Fillable Verification of Disability (City of Pasadena, Texas)

Fill Online, Printable, Fillable, Blank Verification of Disability (City of Pasadena, Texas) Form

Use Fill to complete blank online CITY OF PASADENA, TEXAS (TX) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Verification of Disability (City of Pasadena, Texas)

On average this form takes 4 minutes to complete

The Verification of Disability (City of Pasadena, Texas) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Pasadena, Texas

BROWSE CITY OF PASADENA, TEXAS (TX) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
COMMUNITY DEVELOPMENT DEPARTMENT
CITY OF PASADENA, TEXAS
Verification of Disability
10/2019
CDBG PROGRAM NAME: _______________________________________
APPLICANT NAME: DATE:
APPLICANT’S ADDRESS: CITY: STATE: ZIP:
PURPOSE OF FORM:
In accordance with federal laws and regulations published by the Department of Housing and Urban
Development, it is necessary to verify the disability status of the CDBG Program Applicant identified
hereinabove. All information provided will only be used for the purposes of establishing eligibility documentation
for the above referenced CDBG Program. The City of Pasadena’s Community Development Department and its
Subrecipient Agencies and/or Recipient Departments, are prohibited from asking about the nature of an
applicant’s disability, and medical professionals should not disclose specific details or diagnoses.
A person with disabilities is a person who:
A. Has a physical, mental, or emotional impairment that:
1. Is expected to be of a long, continued, and indefinite duration, and
2. Substantially impedes his/her ability to live independently, and
3. Is of such nature that the ability could be improved by more suitable housing conditions, or
B. Has a developmental disability, as defined, in Section 102(7) of Development Disabilities Assistances and
Bill of Rights Act (42 U.S.C. 6001-6007).
INSTRUCTIONS:
There are three (3) methods of verification of disability status listed below. Please select ONE (1) of the
verification methods and provide the necessary documentation associated with that verification method. A copy
of this form and verification documentation should be placed in the CDBG Program Applicant’s eligibility file.
_____ OBVIOUS DISABILITY
Select this box if the applicant named above, in the reasonable judgement of the CDBG Program Director, has
an obvious disability. Examples of obvious disabilities are blindness or permanent necessity of wheelchair use.
No further verification of disability required.
Signature of CDBG Program Director:
_____ RECEIPT OF FEDERAL DISABILITY BENEFITS
Select this box if the applicant named above receives disability-related Social Security (“SSDI”), Supplemental
Security Income (“SSI”), Veterans’ Administration (“VA”), or other federal benefits. Reasonable
documentation includes a benefit verification letter from the federal agency providing financial assistance to
the applicant or canceled checks or direct deposit documentation or like records. No further verification is
required.
Type of Documentation Provided:
COMMUNITY DEVELOPMENT DEPARTMENT
CITY OF PASADENA, TEXAS
Verification of Disability
10/2019
_____ CERTIFICATION OF A MEDICAL PROFESSIONAL (certification must be made by someone other than applicant)
Select this box if the applicant named above DOES NOT have an obvious disability and/or DOES NOT receive
disability-related federal benefits. If this box is selected the applicant’s disability status can only be verified
through certification by a medical professional by completing the following sections.
To the applicant claiming disability:
The undersigned medical professional has knowledge of whether the claimed disability meets the definition
applicable to this verification so that you may qualify for assistance under the referenced CDBG Program.
YOU ARE NOT OBLIGATED TO CONSENT TO THE RELEASE OF THIS INFORMATION. However,
the CDBG Program Representative must receive the information requested from the medical professional to
determine your eligibility for the CDBG Program. The CDBG Program Representative may request from the
medical professional only the minimum information necessary to determine whether the applicable definition
of disability has been met.
I hereby authorize the release of the requested information to the CDBG Program Representative.
Name of Authorized Person:
Signature of Authorized Person:
Date:
To the medical professional:
The City of Pasadena’s Community Development Department and its Subrecipient Agencies and/or Recipient
Departments have an obligation with the United States Department of Housing and Urban Development
Community Development Block Grant Program to verify disability when providing assistance utilizing federal
funds. The applicant has asserted that he/she has a disability which must be documented by a medical
professional. An authorized individual has lawfully consented to release to the CDBG Program Representative
the medical opinion below regarding the claimed disability status. All information provided by a medical
professional will be used solely to establish disability status. Neither the City of Pasadena’s Community
Development Department nor its representatives may ask about the nature of an individual’s disability, and
medical professionals should not disclose specific details or diagnoses.
I hereby certify that the above-named applicant (check one) ___ DOES / ___ DOES NOT meet the definition
of person with disabilities set forth in this verification
Signature of Medical Professional:
Title and Organization:
Date:
SIGNATRUES:
Under penalties of perjury, I certify that the information presented in this document is true and accurate to the best of my
knowledge and belief. I further understand that providing false representations herein constitutes an act of fraud. False,
misleading or incomplete information may result in my ineligibility to participate in CDBG Programs that will accept this
document. WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE CLAIM OR STATEMENT OT HUD MAY BE SUBJECT
TO CIVIL OR CRIMINAL PENALTIES UNDER 18 U.S.C. 287, 101 AND 31 U.S.C. 3729.
CDBG Program Representative Name:
Date:
CDBG Program Representative Signature:
Applicant’s Name:
Date:
Applicant’s Signature:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Verification of Disability (City of Pasadena, Texas)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document