Accessible Unit Application Form

ACCESSIBLE UNIT APPLICATION FORM

WHEREAS

WHEREAS the Housing Provider: (hereinafter "Provider") manages residential units and maintains an accessible unit program; and

WHEREAS the Applicant: seeks consideration for placement into an accessible unit or for reasonable accommodation under the Provider's policies; and

WHEREAS the parties desire to record the Applicant's information, requested accommodations, and preliminary terms for occupancy and payment pending final eligibility determination and a separate occupancy agreement;

APPLICANT INFORMATION

HOUSEHOLD COMPOSITION

ACCESSIBILITY NEEDS

Please indicate the features you require. Check all that apply:

REASONABLE ACCOMMODATION REQUEST

The Applicant requests the following reasonable accommodation or modification to standard unit features. Provide a detailed description of the accommodation sought and the functional limitation that it addresses.

Supporting documentation attached: Medical/provider statement Other documentation

INCOME AND PAYMENT INFORMATION

UNIT PREFERENCES

Preferred unit size (select one):

PRELIMINARY PAYMENT TERMS (FOR APPLICATION PURPOSES)

The following payment terms describe anticipated rent and charges should the Applicant be approved. Final terms will be set in a separate occupancy agreement.

Late payment: A late fee equal to of the unpaid rent may be assessed if rent is not received within days after the due date, subject to applicable law.

TERM AND TERMINATION

The parties acknowledge that any occupancy resulting from this application is to commence on: and shall continue through:

Either party may terminate a confirmed occupancy in accordance with the notice period specified in the final occupancy agreement. For planning purposes, provide required notice period in days:

CONFIDENTIALITY

All personal information and supporting documentation submitted by the Applicant will be treated as confidential and retained only as necessary for eligibility determination, occupancy processing, and compliance with legal obligations. Provider will store and handle medical or disability-related documentation in a secure manner and will disclose such records only to staff with a legitimate need to evaluate the request or as required by law.

GOVERNING LAW

This application and any subsequent occupancy agreement shall be governed by the laws of the state in which the property is located. Provider and Applicant expressly agree to comply with applicable federal and state civil rights and housing laws, including statutes prohibiting discrimination on the basis of disability.

ENTIRE AGREEMENT

Except for a subsequent executed occupancy agreement, this application, together with any attachments and signed reasonable accommodation request, constitutes the complete record of the Applicant's submission regarding placement into an accessible unit. No oral statements or prior representations shall have binding effect unless reduced to writing and signed by an authorized representative of the Provider and the Applicant.

CERTIFICATION AND AUTHORIZATION

I certify under penalty of perjury that the information provided in this application is true and correct to the best of my knowledge. I authorize Provider and its agents to verify the information provided, to request supporting documentation, and to communicate with third parties as necessary to evaluate this application and accommodation request. I understand that submission of this application does not guarantee placement or an executed occupancy agreement.

ADDITIONAL AUTHORIZATIONS

Applicant consents to reasonable inspections of the proposed unit and to the Provider's verification of income, disability-related documentation, and references necessary to evaluate eligibility. Applicant may request return or destruction of medical documentation after the eligibility determination in accordance with Provider policy.

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