HUD 90103 Sample Verificaiton of disability All Programs

SAMPLE VERIFICATION OF
DISABILITY

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0204
(exp.03/31/2011)

ALL PROGRAMS EXCEPT
SECTION 202/8, SECTION 202 PAC,
SECTION 202 PRAC, AND
SECTION 811 PRAC

Appendix 6-B: SAMPLE VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION OR
QUALIFICATION FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY
FOR USE WITH ALL PROGRAMS EXCEPT SECTION 202/8, SECTION 202 PAC,
SECTION 202 PRAC, AND SECTION 811 PRAC
DATE:
TO:

(Name and address of third party
who is being requested to verify
this information)

FROM: (Name of individual
requesting the information,
title, name of the housing project,
address)

RETURN THIS VERIFICATION TO THE PERSON LISTED ABOVE (or other instructions to the third party
to ensure that the verification is returned to the right person. This is important because owners have a
responsibility to treat this information confidentially.)
SUBJECT:

Verification of Disability
NAME___________________________________________________________
ADDRESS________________________________________________________

This person has applied for housing assistance under a program of the U.S. Department of Housing and
Urban Development (HUD). HUD requires the housing owner to verify all information that is used in
determining this person’s eligibility or level of benefits.
We ask your cooperation in providing the following information and returning it to the person listed at the
top of the page. Your prompt return of this information will help to ensure timely processing of the
application for assistance. Enclosed is a self-addressed, stamped envelope for this purpose. The
applicant/tenant has consented to this release of information as shown above.
===================================================================
INFORMATION BEING REQUESTED
For each numbered item below, mark an “X” in the applicable box that accurately describes the person
listed above.
1. ___YES ___NO

APPENDIX 6-B

Has a disability, as defined in 42 U.S.C. 423, which means;
a.
Inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment that can be
expected to result in death or that has lasted or can be expected to
last for a continuous period of not less than 12 months; or

1 of 4

Form HUD-90103
12/2007

SAMPLE VERIFICATION OF
DISABILITY

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0204
(exp.03/31/2011)

ALL PROGRAMS EXCEPT
SECTION 202/8, SECTION 202 PAC,
SECTION 202 PRAC, AND
SECTION 811 PRAC

b.

In the case of an individual who has attained the age of 55 and is
blind, inability by reason of such blindness to engage in substantial
gainful activity requiring skills or abilities comparable to those of any
gainful activity in which he/she has previously engaged with some
regularity and over a substantial period of time.
For the purposes of this definition, the term blindness, as defined in
section 416(i)(1) of this title, means central vision acuity of 20/200 or
less in the better eye with use of a correcting lens. An eye which is
accompanied by a limitation in the fields of vision such that the widest
diameter of the visual field subtends an angle no greater than 20
degrees shall be considered for the purposes of this paragraph as
having a central visual acuity of 20/200 or less.

2. ___YES ___NO

Has a physical, mental, or emotional impairment that:
a.
Is expected to be of long-continued and indefinite duration;
b.
Substantially impedes his or her ability to live independently; and
c.
Is of such a nature that the ability to live independently could be
improved by more suitable housing conditions.

3. ___YES ___NO

Has a developmental disability as defined in Section 102(7) of the
Developmental Disabilities Assistance and Bill of Rights Act 42 U.S.C.
6001(8)), i.e., a person with a severe chronic disability that:
a.
Is attributable to a mental or physical impairment or
combination of mental and physical impairments;
b.
Is manifested before the person attains age 22;
c.
Is likely to continue indefinitely;
d.
Results in substantial functional limitation in three or more of the
following areas of major life activity:
(1)
Self-care,
(2)
Receptive and expressive language,
(3)
Learning,
(4)
Mobility,
(5)
Self-direction,
(6)
Capacity for independent living, and
(7)
Economic self-sufficiency; and
e.
Reflects the person's need for a combination and sequence of
special, interdisciplinary, or generic care, treatment, or other services
that are of lifelong or extended duration and are individually planned
and coordinated.

APPENDIX 6-B

2 of 4

Form HUD-90103
12/2007

SAMPLE VERIFICATION OF
DISABILITY

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0204
(exp.03/31/2011)

ALL PROGRAMS EXCEPT
SECTION 202/8, SECTION 202 PAC,
SECTION 202 PRAC, AND
SECTION 811 PRAC

4. ___YES ___NO

Is the above a person whose disability is based solely on any drug or
alcohol dependence (the person has no other disability which meets the
above definition).

____________________________
NAME AND TITLE OF PERSON
SUPPLYING THE INFORMATION

_______________________________
FIRM/ORGANIZATION

____________________________
SIGNATURE

________________________________
DATE

============================================================================
Public reporting burden for this collection is estimated to average 12 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. This information is required to obtain benefits and is voluntary. HUD may not collect this information,
and you are not required to complete this form, unless it displays a currently valid OMB control number. Owners/management
agents must obtain third party verification that a disabled individual meets the definition for persons with disabilities for the
program governing the housing where the individual is applying to live. The definitions for persons with disabilities for programs
covered under the United States Housing Act of 1937 are in 24 CFR 403 and for the Section 202 and Section 811 Supportive
Housing for the Elderly and Persons with Disabilities in 24 CFR 891.305 and 891.505. No assurance of confidentiality is provided.
The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing
Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181);
the Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and
Community Development Act of 1987 (42 U.S.C. 3543).

APPENDIX 6-B

3 of 4

Form HUD-90103
12/2007

SAMPLE VERIFICATION OF
DISABILITY

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0204
(exp.03/31/2011)

ALL PROGRAMS EXCEPT
SECTION 202/8, SECTION 202 PAC,
SECTION 202 PRAC, AND
SECTION 811 PRAC

========================================================================
RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is
limited to information that is no older than 12 months. There are circumstances that would require the owner to verify
information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of
this consent.

Signature

Date

Note to Applicant/Tenant: You do not have to sign this form if either the requesting organization or the organization
supplying the information is left blank.
========================================================================
PENALTIES FOR MISUSING THIS CONSENT:
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to any department of the United States Government. HUD and any owner (or any
employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of
information collected based on the consent form. Use of the information collected based on this verification form is
restricted to the purposes cited above. Any person who knowingly or willingly
requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be
subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent
disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the
officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty
provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and
(8). Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).

APPENDIX 6-B

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Form HUD-90103
12/2007