Request for Reasonable Accommodation
Requested By:
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==Please select==
Person with Disabilities
On behalf of person with disabilities
Phone Number:
*
I (Resident Full Name):
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Street Address:
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City:
*
State:
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Postal / Zip Code:
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I hereby request a reasonable accommodation for the following reason:
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The Housing Authority of the City of Freeport may contact the following person(s) (Doctor, Conselor, Casweworker, etc.) to verify the need for the accomodation requested:
Can we contact the person(s) above?:
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Yes
No
E-Signature:
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