Baltimore Regional Housing Partnership | Reasonable Accommodations Request Form

Reasonable Accommodation Form

This form should be used by clients to request reasonable accommodation for their disability so that they can participate in BRHP activities and access housing.

Disabled clients can expect reasonable accommodations that help them to have an equal chance to take part in the Baltimore Housing Mobility Program or to access housing. The accommodation(s) must directly relate to the person’s disability.

You are not required to use this form. The Program will consider spoken or other written requests. However, it is best to document the request in writing.

Before approving a request, the Baltimore Regional Housing Partnership (BRHP) must verify that the person meets the definition of disabled under the Fair Housing Act and that the request will improve the person’s access to BRHP’s program and services. Other documentation may be required to process the request.
Head of Household Name
First Last
Disabled Family Member Name
First Last
What accommodations do you need in order to use BRHP's program or services? (Do not include any details about the extent of the disability, treatment information, or other confidential or medical information.)
The Baltimore Regional Housing Partnership, under the Fair Housing Act, can obtain information that is necessary to evaluate if a requested for reasonable accommodation is necessary because of a disability. Depending on individual circumstances, third party verification may be required.

A doctor or other medical professional, a peer support group, a non-medical service agency, or a reliable third party who is in a position to know about the individual’s disability may provide verification of a disability. Please place your third-party’s contact information below.
Third-Party Contact Information
Provider Name
First Last
Organization or Business:
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number
Fax Number
Email Address
Consent for Information Release
The purpose of your signature is to obtain verification of your disability that is relevant to the Baltimore Housing Mobility Program to determine if you are eligible for your requested accommodation. Your signature below authorizes the Baltimore Regional Housing Partnership to obtain verification from the reliable third party, such as a doctor or other medical professional, named on this form.
By signing below, I hearby authorize the release on the requested information
Signature
Date
MM slash DD slash YYYY

Reasonable Accommodation Form

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