2015 Washington Affordable Housing Management
Convention
Why Fair Housing?
Sample Forms
© 2015 Theresa L. Kitay - Samples Only
Always consult your legal advisor
REASONABLE ACCOMMODATIONS VERIFICATION FORM
[3URSHUW\] provides reasonable accommodations to our clients with disabilities who have a
verifiable need for the reasonable accommodation. A reasonable accommodation is an exception
made to the usual rules or policies made necessary because of a disability for the resident to
use and enjoy housing. The resident has authorized you to provide the information requested on
this form. Please answer the following questions:
Name of Resident (print): __________________________________________
Request for Reasonable Accommodation: ____________________________
Signature of Resident:_______________________________________________________
This signature authorizes the verifier to provide answers to the questions below to the best of his/
her knowledge of this resident.
1. Is this resident disabled?
The Fair Housing Act and Section 504 of the Rehabilitation Act of 1973 define disability as a
physical or mental impairment that substantially limits one or more major life activities. The
Supreme Court has determined that to meet this definition a person must have an
impairment that prevents or severely restricts the person from doing activities that are
of central importance in most peoples’ daily lives.
YES
NO
I DON’T KNOW
2. Please describe in what manner this disability restricts the resident in activities that are of
central importance to his or her daily life:
3. Does this resident need the accommodation requested above to be able to live in his/her
housing?
YES
NO
4. If yes, please describe how this accommodation will enable the resident to use or enjoy
housing.
5. If necessary will you be willing to testify in a court of law concerning the information
provided in this form?
YES
NO
Name and position of verifier:
(Please print)_____________________________________________________
Signature of Verifier: _________________________ Date: _________________
Address: ________________________________________________________
Telephone: ______________________________________________________
© 2011 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Contact your legal advisor prior to use
RESIDENT’S REASONABLE ACCOMMODATION REQUEST FORM
[Name of property] is committed to the letter and spirit of the Fair Housing Act, which, among
other things, prohibits discrimination against persons with disabilities. In accordance with our
statutory responsibilities and management policies, we will make reasonable accommodations in
our rules, policies, practices, or services, or allow reasonable modifications to the property, when
such accommodations or modifications may be necessary to afford persons with disabilities an
equal opportunity to use and enjoy their housing communities. If you are requesting such an
accommodation, please fill out this form and return it to the manager.
Resident’s Name:
________________________________________________
Address:
________________________________________________
Date of Request:
________________________________________________
Please describe the accommodation (exception to our usual rule or policy) or modification
(physical change to the property) that you are requesting:
________________________________________________________________
________________________________________________________________
1.
Do you consider yourself to be disabled?
The Fair Housing Act defines disability as a physical or mental impairment that substantially
limits one or more major life activities. The Supreme Court has determined that to meet this
definition a person must have an impairment that prevents or severely restricts the person
from doing activities that are of central importance in most peoples’ daily lives.
YES
2.
NO
Please describe how the requested accommodation or modification is necessary for your
use and enjoyment of your apartment community? (If needed, you may write on the back
of this form or attach additional sheets of paper.)
_____________________________________________________________
_____________________________________________________________
___________________________________________________________
Please return this request to the office. If you have been asked to provide verification of this
request, please identify the third party professional we should contact below:
Name: _______________________________________
Position:
_______________________________________
Address:
_______________________________________
_______________________________________
Telephone:
_______________________________________
© 2011 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Contact your legal advisor prior to use
ANIMAL AGREEMENT
THIS AGREEMENT entered into this _______ day of ____________, by and
between _________________, Owner/Agent and __________________,Tenant,
in consideration of their mutual promises agree as follows:
1. Tenant has requested permission from the owner to keep an animal as a
reasonable accommodation due to a disability.
2. Management has confirmed that the Tenant or a household member has a
disability and, if applicable, has verified with a third party professional that the
animal is necessary for the Tenant’s or household member’s use and enjoyment
of the property.
3. The animal needed to provide the accommodation is described below:
__________________________________________________________
4. Tenant will supply landlord with a photograph of the animal by __________(date).
5. Management agrees not to charge a pet deposit for the animal described above
6. Tenant will not acquire additional or different animals without permission of
landlord.
7. Tenant is responsible for the animal and shall comply with all health and safety
codes, and other applicable governmental laws and regulations, such as, but not
limited to licensing, vaccination, and leash and nuisance laws.
8. Tenant agrees to maintain the animal in good health including maintaining proper
annual vaccinations.
9. Tenant represents that the animal is quiet and housebroken, and will not cause
any damage or unreasonably annoy other Tenants.
10. Tenant agrees to keeping the animal in his/her control at all times and when it is
necessary to take the animal outside, the animal will be kept on a leash and with
a responsible person at all times.
11. Tenant is responsible to remove and properly dispose of any waste discharge
upon the premises.
© 2011 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Contact your legal advisor prior to use
Assist Animal Agreement
Page 2
12. Animals are allowed in the common areas, only to the extent that they allow the
Tenant equal access and enjoyment to the common area facilities.
13. Should the animal become a direct threat to the health and safety of members of
management, other Tenants or their guests, permission to keep the animal shall
be revoked and the animal shall be removed from the premises within 24 hours.
14. Any animal left unattended for 12 hours or more, or whose health is jeopardized
by the Tenant’s neglect, mistreatment, or failure to care for the animal, shall be
reported to the Humane Society or other appropriate authority. Such
circumstances shall be deemed an emergency for the purposes of the Owner/
Agent’s right to enter the Tenant’s unit to allow such authority to remove the
animal from the Premises. The Owner/Agent accepts no responsibility for any
animal so removed.
15. Tenant agrees to indemnify, defend, and hold Owner/Agent harmless from and
against any and all claims, actions, suits, judgments, and demands brought by
any other party on account of or in connection with any activity or damage
caused by the Tenant’s animal.
16. Tenant will reimburse landlord for any damage to the unit caused by or resulting
from the animal, including replacement of the pad and carpeting, if necessary.
17. This addendum is incorporated into the Lease Agreement and Tenant agrees to
abide by each and all such rules. Failure to comply may allow Owner/Agent to
terminate the Lease Agreement as provided by the state landlord/tenant law.
18. Tenant has read this Agreement and the Assist Animal information attachment
and agrees to comply with the terms of the Agreement and such rules and
regulations as may be reasonably adopted from time to time by Owner/Agent.
______________________
Tenant
_________
Unit No.
__________________
Date
The above named tenant(s) has read and signed this Agreement in my presence.
____________________ _____________________
Owner/Agent
Authorized Representative
© 2011 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Contact your legal advisor prior to use
________________
Date
Request for Preference for UFAS Unit
(To be used in conjunction with waitlist)
Name of applicant or household member who needs the features of an accessible
apartment:
_______________________________________________________________
[PROPERTY NAME] is an community that receives federal financial assistance for its
housing program. Because of that assistance, certain apartments in this community have
additional features of accessibility for persons who have mobility impairments and are in
need of certain special design features. People with disabilities needing these design
features may be entitled to a preference for the available apartments with these
accessibility features for mobility impairments.
PART A - Accessible Features Present in All [Ground Floor] Apartments:
[FOR PROPERTIES THAT ARE NEW CONSTRUCTION AND COMPLIANT WITH
THE CBC’S ACCESSIBILITY REQUIREMENTS ONLY:
Please note that all apartments [all ground floor apartments] at this property have the
features listed below that may benefit a person with a mobility impairment:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Accessible unit entrance
36” wide accessible route through unit
60” turning space in rooms
Accessible thresholds
Accessible parking available
Doors intended to accommodate wheelchair passage
Lever hardware
Maneuvering space at doors
Light switches, electrical outlets, and environmental controls at an accessible
height
In wall reinforcements to allow installation of grab bars at toilet, tub, or shower
Wheelchair approach to toilet and tub or shower
Toilet height of 15” - 19”
Bathroom lavatory with pull under knee space, and maximum height of 34”
Accessible faucet controls on all sinks, tub, or shower
Mirror over lavatory at 40” maximum to bottom of reflecting surface
Wheelchair access to all fixtures in kitchen
30” wide work surface in kitchen
Kitchen sink with pull under knee space
© 2012 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Contact your legal advisor prior to use
_________(property name)
Verification Form for Accessible Unit
Page 2
PART B - UFAS Features in Some Apartments
A small percentage of the units at this property contain additional features of accessibility
for people with mobility impairments, along with the features listed above. These
additional features include:
•
•
•
•
•
•
•
•
•
•
•
•
Doors that are 36” wide
Cabinets with accessible pulls
Closet clothes rods mounted at 54”
Toilet located next to a wall
Toilet paper dispenser located 36” from rear wall
Lowered medicine cabinet
Tub / shower seat
Tub / shower handheld sprayer
Kitchen sink height at 34”
Kitchen work space with pull under knee space
Front controls on range or cooktop
Refrigerator with 100% of refrigerator space and 50% of freezer space below 54”
PART C - Request for Accessible Features
Please circle the response that applies to you (or any member of your household) for
each of the questions below:
YES
NO
I am disabled.
YES
NO
I am disabled, but do not need any
of the features listed above.
YES
NO
I am disabled, and need only the features available in all [ground floor]
units (Part A above).
YES
NO
I am disabled, and need the features available in the specially equipped
units (Part B above).
© 2012 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Contact your legal advisor prior to use
_________(property name)
Verification Form for Accessible Unit
Page 2
PART D - Additional Accessible Features Needed
In addition to the accessible features listed above in Parts A and B, please list any other
features of accessible design which you or any member of your household may require:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PART E - Verification
In some circumstances, we may require third party verification of the information you
have provided. [PROPERTY NAME] will notify you if such verification is necessary.
Please complete the information below:
Name: __________________________________________
Phone Number: ____________________________________
Email: ___________________________________________
Unit Number (if current resident): ____________
© 2012 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Contact your legal advisor prior to use
[PROPERTY NAME]
LEASE ADDENDUM
RESIDENT’S AGREEMENT TO VACATE UFAS ACCESSIBLE UNIT
I acknowledge that I am occupying an apartment that has additional features of accessible design
not present or available in standard apartments at [PROPERTY NAME], known as “UFAS
units”, and that I do not have a disability that benefits from these special design features. I
acknowledge that priority for UFAS units is given to those persons with disabilities who would
benefit from these special physical design features. I acknowledge that I am permitted to occupy
this unit until management issues me notice that a priority applicant is on the transfer list or the
waiting list. At that time, I will be required to move to the next available appropriately sized unit
at [PROPERTY NAME]. Upon issuance of the notice that a vacant appropriately sized unit is
available and that my current unit is needed by a person with a disability who would benefit from
the special features of a UFAS unit, I agree to move to the vacant unit within the community
within thirty (30) days of that notice. I understand that the costs of my move will be borne by
(resident) (owner).
This will serve as an addendum to my lease agreement with [PROPERTY NAME].
_______________________________________
_________________
Resident’s Signature
Date Signed
___________________________________
_________________
Manager’s Signature
Date Signed
© 2012 Theresa L. Kitay, Attorney at Law
SAMPLE ONLY - Consult your legal advisor prior to use
7111 NE 179th Street, Vancouver, WA 98686-1888 ∙ Tel: 360-574-9035 ∙ Fax: 360-574-9401 ∙
www.affordablehousinginsurance.org
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Coverage for Property/ AM BEST rated A+XV ( PESLIC )
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$2 million occurrence with an unlimited aggregate / hired & non-owned auto / property
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tenant discrimination (sublimit of $150,000) / excess liability limits available up to $8 million
Name:
Company name:
Email:
Phone number:
Name and address of complex:
Building / contents / annual rents – total combined value: $
Number of units:
Please return information to Gil Stuart at [email protected] or 360-574-9035 x103