Sample Verification for Reasonable Accommodation/Modification

Re:   (Name) request for a (type of accommodation, example: a reserved accessible parking space adjacent to apartment).

Please accept this correspondence as verification that:

1. I am a (example: licensed medical doctor) .
2. I have treated (name) since (date) for a (physical, mental, etc) condition.  I have evaluated and/or treated him/her (number) times in the last twelve months.
3. (Name) is a person with a disability as defined by the Washington Law Against Discrimination (RCW 49.60).
4. His/her disability affects his ability to (insert).
5. Allowing the accommodation of (insert) is necessary to afford (name) the opportunity to access and fully use and enjoy his/her home.

Please approve (name’s) request for (accommodation/modification request).

Signature:   (Dr. so and so)

Printed Name: ____________________

Professional Title: ______________

Name of Clinic, Hospital, etc.: _______________________________

Address: ___________________________________________

Phone Number: ____________________________

Fax Number: ______________________________

Date: _________________________