Sample: Request for Accommodation/Modification Application

You may use this form to request that The John Stewart Company (JSCo) provide an accommodation to you or any member of your household who has a disability in order to ensure equal opportunity to access and enjoy your dwelling and common areas or make a modification to your apartment or the apartment community which may be necessary to afford a disabled person full enjoyment of the premises.

For the purpose of this form, a person with a disability includes 1) individuals with a physical or mental impairment that limits one or more major life activities; 2) individuals who are regarded as having such an impairment; and 3) individuals with a record of such an impairment.  The term “physical or mental impairment” includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, HIV/AIDS, mental retardation, emotional illness, drug addiction (excluding active users of illegal/controlled substances) and alcoholism.

Date of Request:
Telephone Number:
Name of Applicant/Resident:
E-Mail Address (if any):
Person for whom request is being made:

Relationship to Applicant/Resident: self


1. I am requesting the following accommodation(s)/modification(s):
Need no-stairs option. Elevator ok. Ground floor ok. NO PRINT! Electronic format preferred for written materials, email recommended. If something is “required in writing,” verbal or email should be accepted in lieu of ink. Levered doorknobs and sink faucets needed.

2. The requested accommodation/modification is disability-related in that: I am totally blind, have arthritis in my left knee, and balance and fine motor problems due to Cerebral Palsy.

3.  You may verify the existence of a disability and the need for this request by contacting the following individual who is a medical/social service professional or other third party with sufficient knowledge to provide the information necessary to process this request :
(insert friendly agency info here, including name, address, phone number and e-mail if known here)

4.  I give you permission to contact the above individual(s) for purposes of verifying the existence of the disability and the need for the accommodation/modification requested as well as to ascertain whether there exists other accommodations or modifications which may also meet the needs of the disabled individual identified above.  I understand that the information you obtain will be kept confidential and used solely to process my request.

5.  I certify that the information provided in this request is true and correct and that I understand the information I have supplied above is being relied upon by (name of property/management company) in making decisions relating to the housing of the disabled individual identified herein.
Signature of Applicant/Resident: Date:


Signature of Management Representative                Date

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