REASONABLE ACCOMMODATIONS

ABSENTEE SHAWNEE
HOUSING AUTHORITY
107 N. Kimberly Shawnee, OK 74801-0425
P: (405) 273-1050 F: (405) 275-0678
REASONABLE ACCOMMODATIONS
RENTAL AND HOMEBUYER PROGRAM PARTICIPANTS ONLY
The reasonable accommodation policy is designed to provide a person with a disability the equal opportunity to use and enjoy any dwelling owned and/or managed by the Absentee Shawnee Housing Authority (ASHA).
A request must be submitted with the following documents:
1. Completed Reasonable Accommodation Request Form
2. Verification of disability
The following procedures will be performed by ASHA in order to complete your request.
- ➤ A screening of your current lease status will be performed by Housing Management to determine you are compliant with program requirements.
- ➤ A screening of your request will be performed by Housing Management to determine eligibility for Reasonable Accommodation. Note: If the reasonable accommodation is for a service or support animal, additional documentation may be required.
- ➤ The reasonable accommodation must be approved by the Executive Director.
- ➤ A written or verbal response will be provided by ASHA within 7-10 business days from the date the request was received.
Return this form to:
Absentee Shawnee Housing Authority
ATTN: Housing Management
107 N. Kimberly Ave.
Shawnee, OK 74801-0425

ABSENTEE SHAWNEE HOUSING AUTHORITY
107 N. Kimberly Shawnee, OK 74801-0425
P: (405) 273-1050 F: (405) 275-0678
REASONABLE ACCOMMODATION REQUEST FORM
A participant or household member with a disability may use this form to request reasonable accommodation. This form must be completed and submitted to housing staff for review.
Please ensure all sections are completed and any required documentation is attached. If you need assistance completing this form, someone may help you.
1. Applicant Information
Tenant Name:
Tenant Address:
Date:

MonthDayYear
Date
The person requiring reasonable accommodation is:
If Household Member, Name:
Phone Number:
Format: (000) 000-0000.
2. Accommodation Requested
Please describe the accommodation you are requesting so you or your household member can fully use and enjoy your housing:

ABSENTEE SHAWNEE HOUSING AUTHORITY
107 N. Kimberly Shawnee, OK 74801-0425
P: (405) 273-1050 F: (405) 275-0678
3. Reason for Request
Please explain why this accommodation is needed:
4. Verification of Disability Status
To Be Completed by Verifying Individual
Name of Person Verifying Disability:
Include an attached document on letterhead signed by the verifying individual. Verification may be completed by a medical professional, a licensed medical service provider, Social Security Administrator, VA administrator or any other authority recognized under applicable governing law, who has access to the medical information of the requestor.
Contact Information:
Address:
Phone:
Format: (000) 000-0000.
Consent and Authorization
As a participant or household member of the Absentee Shawnee Housing Authority, I authorize any federal, state, or local agency, organization, business, or individual to release information necessary to verify my application and/or maintain my housing assistance.
I understand that this information may be shared with the U.S. Department of Housing and Urban Development (HUD) for the purpose of administering and enforcing program rules and policies.

A B S E N T E E S H A W N E E

HOUSING AUTHORITY

107 N. Kimberly Shawnee, OK 74801-0425
P: (405) 273-1050 F: (405) 275-0678
By signing below, I confirm that I understand and agree to the terms of this request. The Absentee Shawnee Housing Authority will notify you within ten (10) business days of approval or denial.
Participant Signature:
Date:

MonthDayYear
Date
Privacy Act Statement
This information is collected in accordance with Part 256 of 25 CFR under the authority of the Snyder Act (25 USC 13). It will be used by housing staff to determine eligibility for housing assistance programs. Information may also be shared with tribal or federal officials during program reviews or audits, or with law enforcement agencies if a violation of civil or criminal law is suspected. Providing this information is required to determine eligibility for program participation.
Section for ASHA Personnel USE only
Housing Management
Signature:
Date:

MonthDayYear
Date
Accommodation Request Status
Executive Director
Executive Director Decision
Signature:
Date:

MonthDayYear
Date
Should be Empty:

ABSENTEE SHAWNEE HOUSING AUTHORITY