COMMUNITY DEVELOPMENT DEPARTMENT
CITY OF PASADENA, TEXAS
Verification of Disability
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).
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.
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
Type of Documentation Provided: