Fillable Verification of Disability (City of Pasadena, Texas)

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Verification of Disability (City of Pasadena, Texas)

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COMMUNITY DEVELOPMENT DEPARTMENT
CITY OF PASADENA, TEXAS
Verification of Disability
10/2020
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
10/2020
_____ 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:
SIGNATURES:
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 TO 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:
COMMUNITY DEVELOPMENT DEPARTMENT
CITY OF PASADENA, TEXAS
Verification of Disability
10/2020
CDBG PROGRAM NAME: _______________________________________
NOMBRE DEL SOLICITANTE: FECHA:
DIRECCION: CIUDAD: ESTADO: CODIGO POSTAL:
PROPOSITO DE LA FORMA:
De acuerdo con las leyes y regulaciones federales publicadas por el Department of Housing and Urban Development, es
necesario verificar el estado de discapacidad del Solicitante del Programa CDBG identificado anteriormente. Toda la
información proporcionada solo se utilizará con el propósito de establecer la documentación de elegibilidad para el
Programa CDBG mencionado anteriormente. El Community Development Department de la Ciudad de Pasadena y sus
Agencias Subrecipientes y/o Departamentos de Destinatarios tienen prohibido preguntar sobre la naturaleza de la
discapacidad del solicitante, y los profesionales médicos no deben revelar detalles o diagnósticos específicos.
Una persona con discapacidad es una persona que:
A. Tiene un impedimento físico, mental o emocional que:
1. Se espera que sea de una duración larga, continua e indefinida, y
2. Impide sustancialmente su capacidad de vivir de forma independiente, y
3. Es de tal naturaleza que la capacidad podría mejorarse mediante condiciones de vivienda más adecuadas, o
B. Tiene una discapacidad del desarrollo, como se define, en la Section 102(7) of Development Disabilities Assistances
and Bill of Rights Act (42 U.S.C. 6001-6007).
INSTRUCTIONS:
Existen tres (3) métodos de verificación del estado de discapacidad que se enumeran a continuación. Seleccione UNO (1)
de los métodos de verificación y proporcione la documentación necesaria asociada con ese método de verificación. Se de
verificación. Se debe colocar una copia de este formulario y la documentación de verificación en el archivo de elegibilidad
del solicitante del programa CDBG.
_____ DISCAPACIDAD OBVIO
Seleccione esta casilla si el solicitante mencionado anteriormente, a juicio razonable del Director del Programa
CDBG, tiene una discapacidad obvia. Ejemplos de discapacidades obvias son la ceguera o la necesidad
permanente del uso de sillas de ruedas. No se requiere verificación adicional de discapacidad.
Firma del Director del Programa CDBG:
_____ RECIBO DE BENEFICIOS FEDERALES POR DISCAPACIDAD
Seleccione esta casilla si el solicitante mencionado anteriormente recibe Seguro Social relacionado con la
discapacidad (“SSDI”), Ingreso de Seguridad Suplementario (“SSI”), Administración de Veteranos (“VA”) u
otros beneficios federales. La documentación razonable incluye una carta de verificación de beneficios de la
agencia federal que proporciona asistencia financiera al solicitante o cheques cancelados o documentación de
depósito directo o registros similares. No se requiere más verificación.
Tipo de documentación proporcionada:
COMMUNITY DEVELOPMENT DEPARTMENT
CITY OF PASADENA, TEXAS
Verification of Disability
10/2020
_____ CERTIFICACION DE UN PROFESIONAL MEDICO (la certificacion debe ser realizada por alguien que no sea el solicitante)
Seleccione esta casilla si el solicitante mencionado anteriormente NO tiene una discapacidad obvia y/o NO
recibe beneficios federales relacionados con la discapacidad. Si se selecciona esta casilla, el estado de
discapacidad del solicitante solo se puede verificar mediante la certificación de un profesional médico
completando las siguientes secciones.
Al solicitante que alega discapacidad:
El profesional médico que suscribe tiene conocimiento de si la discapacidad reclamada cumple con la definición aplicable
a esta verificación aplicable a esta verificación para que pueda calificar para recibir asistencia bajo el Programa CDBG
al que se hace referencia. NO TIENE LA OBLIGACION DE CONSENTIMIENTO PARA LA PUBLICACION DE
ESTA INFORMACION. Sin embargo, el Representante del Programa CDBG debe recibir la información solicitada por
el profesional médico para determinar su elegibilidad para el Programa CDBG. El Representante del Programa CDBG
puede solicitar al profesional médico solo la información mínima necesaria para determinar si se ha cumplido la definición
aplicable de discapacidad.
Por la presente autorizo la divulgación de la información solicitada al Representante del programa CDBG.
Nombre de la persona autorizada:
Firma de la persona autorizada:
Fecha:
Al profesional médico:
El Community Development Department de la Ciudad de Pasadena y sus Agencias Subrecipientes y/o Departmentos de
Desinatrarios tienen una obligación con el United States Department of Housing and Urban Development Community
Development Block Grant para verificar la discapacidad al proporcionar asistencia utilizando fondos federales. El
solicitante ha afirmado que tiene una discapacidad que debe ser documentada por un profesional médico. Una persona
autorizada ha dado su consentimiento legal para divulgar al Representante del Programa CDBG la opinión médica a
continuación sobre el estado de discapacidad reclamado. Toda la información proporcionada por un profesional medico
se utilizara únicamente para establecer el estado de discapacidad. Ni el Community Development Department ni sus
representantes pueden preguntar sobre la naturaleza de la discapacidad de un individuo, y los profesionales médicos no
deben revelar detalles o diagnósticos específicos.
Por la presente certifico que el solicitante mencionado anteriormente (marque uno) ___ Si / ___ No cumple
con la definición de persona con discapacidad establecida en esta verificación.
Firma de profesional médico:
Título y organización:
Fecha:
FIRMAS:
Bajo pena de perjurio, certifico que la información presentada en este documento es verdadera y precisa a mi leal saber y
entender. Además, entiendo que proporcionar declaraciones falsas en este documento constituye un acto de fraude. La
información falsa, engañosa o incompleta puede resultar en mi inelegibilidad para los Programas CDBG que aceptaran este
documento. ADVERTENCIA: CUALQUIER PERSONA QUE HAGA UNA RECLAMACION FALSA O DECLARACION SOBRE EL
HUD PUEDE SER SUJETA A SANCIONES CIVILES O PENALES MENORES DE 18 U.S.C. 287, 101 Y 31 U.S.C. 3729.
Nombre del representante del Programa CDBG:
Fecha:
Firma del representante del Programa CDBG:
Nombre del solicitante:
Fecha:
Firma del solicitante:
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Completed 25 February 2021

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