Authorization to release Information Live-in Aide Request

The U.S. Department of Housing and Urban Development (HUD) regulation (24 CFR 982.316) states: " a family that consists of one or more elderly, near-elderly or disabled persons may request approval for a live-in aide to reside in teh unit and provide necessary support services for a family member who is a person with disabilities".

A Live-in Aide is defined as a person who resides with one or more elderly persons or near-elderly persons or person with disabilities and who: 1) is determined to be essential to the care & well being of the persons; 2) is not obligated for the support of the persons; & 3: would not be living in the unit except to provide the necessary support services.

Tenant Name

First Name Last Name

Tenant Phone Number

Area Code Phone Number

Tenant Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Name of Disabled/Elderly Family Member:

First Name Last Name

Name of requested Live-in Aide:

First Name Last Name

What are the qualifications of the Live-in Aide that will provide the needed care?

If you or anyone in your family is a person with disabilities & you require a specific accommodations in order to fully utilize our programs & services, please contact our office at 870-226-2600.

Aide Form
Physician Form