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City of South Bend, Indiana <br />Reasonable Accommodations <br />VERIFICATION OF DISABILTIY STATUS <br />Definitions: <br />Federal law provides in part that "persons with disabilities" are persons who: (1) have any "physical or <br />mental impairment" that substantially limits one (1) or more "major life activities'; or (2) has a record of <br />having such impairment; or (3) is regarded by others as having such impairment. <br />A "major life activity" is any task central to most people's daily lives, such as caring for oneself, <br />performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. <br />A "physical or mental impairment" includes, but is not limited to orthopedic, visual, speech and hearing <br />impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, <br />diabetes, mental retardation, emotional illness, learning disabilities, HIV disease (whether symptomatic <br />or asymptomatic), tuberculosis, drug addiction (except illegal drugs) and alcoholism. Short term, <br />temporary health conditions shall not be included. <br />Verification: <br />To the best of my knowledge, information and belief, the person(s) who occupy (or who will occupy) the <br />dwelling that is subject to the above request for a reasonable accommodation --- do do not meet the <br />definition of "persons with disabilities ". I am in a position to know about the person(s)' disabilities <br />because <br />(For example, are you a medical or social services professional, part of a peer support group that serves <br />the person(s), or someone who resides with the person ?) <br />[NOTE: Do NOT reveal the nature or severity of the persons' disabilities.] <br />I affirm under penalty of perjury that the information provided in this Verification of Disability Status is <br />true and accurate. <br />Printed name: <br />Signature: <br />Address: <br />Telephone # <br />16 <br />