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Notice of Right and Request for a Reasonable Accommodation – New Request

Notice of Right and Request for a Reasonable Accommodation – New Request

Fill out this form to certify your notice of a right to a reasonable accommodation, request a new reasonable accommodation, or renew an existing one if the verification time frame has expired.

After submitting this form, you will receive an email with a copy of the completed form for your records.

Receive This Form by Mail or Pick-Up

If you do not want to complete this form online, you can call our main office to have it mailed to you. You can also pick it up in the office.

Berkeley Housing Authority
1947 Center Street Fifth Floor, Berkeley, CA 94704
Telephone: (510) 981-5470 Fax: (510) 981-5480

Notice of Right and Request for a Reasonable Accommodation - New Request

"*" indicates required fields

Step 1 of 2

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Notice of Right to Reasonable Accommodation

If you or a family member has a disability and as a result of the disability you need:

A modification to our rules or policies such as permission for a live in aid, additional time to search for housing, or other changes to our rules; or
A change in the way we communicate with you or give you information, you may ask for this kind of rule or policy change by requesting a reasonable accommodation.
A structural modification to your unit, or a move to a different unit (Low Income Public Housing Units only)
Accommodation of a service or companion animal

Select your request

I would like to request a reasonable accommodation.

I already am receiving a reasonable accommodation and would like to continue receiving it.

I do not request a reasonable accommodation (sign below).

If you have a disability as verified by a medical professional, and if your request for an accommodation is directly related to your disability, reasonable (it does not pose and “undue financial or administrative burden”), and does not violate or conflict with a basic program element (payment of rent, inspections, and responsibility to be a good neighbor) or result in an undue financial or administrative burden to the BHA, we will grant the change you request.

How to Request a Reasonable Accommodation

Step 1: Select "I would like to request a reasonable accommodation" from the choices above. A second page of this form will populate and will need to be completed. You may complete the form or you may have the help of a family member or other person you designate. If you require further assistance please contact your Housing Authority representative.

Step 2: We will need verification that you have a disability from a healthcare provider that you identify on the back of this form. Once we receive verification from your healthcare provider, we will respond to you in writing within five to ten business days of receiving the information we need.

Response: Your request will either be approved, denied or reviewed with an alternative suggestion. If your request is denied we will give you an opportunity to appeal and provide us with additional information. If you have any questions on this process, please call the Reasonable Accommodations Coordinator at 510-981-5485.

Please sign to acknowledge receipt of a copy of this notice.

Name*

First

Email*

Enter Email Confirm Email

Phone*

Legal Consent*

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

I agree to the terms and conditions.

Signature*

Date*

MM slash DD slash YYYY

Request for a Reasonable Accommodation

Name of Head of Household*

First

Head of Household's Phone*

Head of Household's Email

Enter Email Confirm Email

Address*

Street Address Apt City State ZIP Code

Name of Housing Specialist

First

Reasonable accommodations allow everyone, regardless of ability, to have an equal opportunity to use and enjoy participation in rental assistance programs managed by the Berkeley Housing Authority (BHA). If you need assistance completing this form, please contact your Housing Specialist.

1. The following household member has a disability:*

First

2. Describe the accommodation you are requesting:*

Permission for an aide to live with me to provide assistance with daily living activities

Additional time to search for suitable housing

Exception utility allowance to cover increased costs of electricity and/or gas for equipment and/or heating [Note: you will need to apply for Medical Baseline Rate through PG&E]

Translation of documents into Braille, large print or audio tape

Home visit by Housing Authority representative to conduct re-certifications

Service or assistance animal [Note: you will need a letter from your care provider to provide to your landlord or prospective landlord]

Other

Other Accommodation*

Please describe the accommodation you are requesting.

3. Describe why this accommodation is needed and how it relates to a disability:*

4. List the name and contact information of the individual who can verify the disability and the need for the accommodation requested. This should be an individual providing professional services that relate to the disability.*

Name

Position

Address

Phone Number

Fax Number

Authorization to Release Information*

I authorize the care provider listed above to disclose relevant information to the Berkeley Housing Authority regarding the need for a reasonable accommodation. I understand the information BHA obtains will be kept confidential and used solely to determine if an accommodation should be provided. I hereby authorize my healthcare provider (named above) to release the requested information on the “Verification of Need for Reasonable Accommodation” form to the Housing Authority.

I agree to the terms above.

Your Name*

First

Phone*

Legal Consent*

I agree to the terms and conditions.

Your Signature*

Today's Date*

MM slash DD slash YYYY

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Berkeley Housing Authority
1947 Center Street Fifth Floor, Berkeley, CA 94704
Telephone: (510) 981-5470 Fax: (510) 981-5480