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A %ui�isa o <br />City of South Bend, Indiana <br />Reasonable Accommodations Attachment # 1 <br />APPLICATION FORM TO REQUEST A REASONABLE ACCOMMODATION <br />A reasonable accommodation is any modification of a zoning rule, policy, practice or procedure if the <br />modification is reasonable and necessary in order to give a person with disabilities an equal opportunity <br />to use and enjoy a dwelling in the City of South Bend, Indiana.* <br />If you believe that you need a reasonable accommodation to live in a dwelling, or so that persons with <br />disabilities may live in a dwelling that you own or operate, please complete this application form and <br />return it to: <br />Zoning Administrator <br />Building Department <br />125 South Lafayette Boulevard, Suite 100 <br />South Bend, Indiana 46601 <br />Please attach additional pages if necessary. If you have questions or need assistance, please call the <br />Building Department at (574) 235 -9554 or fax the Building Department at (574) 235 -5541. <br />Name and Contact Information of Applicant: <br />Name: <br />Street Address: <br />City, IN Zip Code: <br />Telephone: Landline: - Cell: <br />Are the persons who currently live at the dwelling persons with disabilities? Yes No <br />Are the persons who plan to live at the dwelling persons with disabilities? _ Yes No <br />If you answered yes, you must submit the verification of disability status form below. <br />*A person with a disability is anyone who has a physical or mental impairment that substantially limits <br />one (1) or more major life activities; or has a record of having such impairment; or is regarded by others <br />as having such impairment. <br />11 <br />