Reasonable Accommodations Form

Reasonable Accommodations Form
A reasonable accommodation is any modification or waiver of zoning requirements, policies, or practices if the modification is reasonable and necessary in order to give a person with disabilities an equal opportunity to use and enjoy a dwelling in the City of South Bend, Indiana.

A person with a disability is anyone who has a physical or mental impairment that substantially limits one (1) or more major life activities; or has a record of having such impairment.

If you have any questions or need assistance, please call the South Bend Zoning Office at 574-235-7627.

Applicant Information
Name:

First NameLast Name
Relationship to the property

Other
Mailing address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Disability Status
Do current residents of the dwelling have disabilities?
Will people with disabilities live at the dwelling in the future?
Property Information
Property address subject to request

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parcel ID
Is there a contingent purchaser?
Contingent purchaser name

First NameLast Name
Contingent purchaser mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contingent purchaser phone number
Please enter a valid phone number.Format: (000) 000-0000.
Contingent purchaser email address
example@example.com
Filing For Information
Are you filing on behalf of an organization or business?
Name of organization registered with the Indiana Secretary of State
Agent of record with Indiana Secretary of State
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Employer identification number (EIN)
City of South Bend license/permit number (if any)
The Accommodation Request
How is the property currently used and zoned?
Describe how the property is being used right now (e.g., single-family home, vacant, group home) and its zoning district if you know it (e.g., S1, U1, NC). If you don't know the zoning, write 'Unknown' — the Zoning Administrator can look it up.
What accommodation are you requesting?
Be specific. Examples: 'Waive the two-unrelated-persons limit so eight residents and one staff member can live in the home as a recovery residence.' 'Allow a wheelchair ramp to encroach two feet into the front setback.' If you know which section of the zoning ordinance you'd like waived, cite it — but it's not required.
Why is this accommodation necessary?
Explain how the current zoning rule prevents people with disabilities from living in the dwelling, and how the accommodation would solve that. The legal standard is whether, without the accommodation, the person would be excluded from the neighborhood. You do not need to disclose specific medical conditions.
Is the dwelling licensed by the State of Indiana?
Type of state license
Upload copy of license

Cancelof
Occupancy and Dwelling Details
Are you requesting to house more than two unrelated persons in a single-family-zoned dwelling?
Number of residents who will live in the dwelling (excluding staff)
Number of required staff who will live in the dwelling
Total square footage of the dwelling
Total number of bedrooms in the dwelling
For each bedroom, provide the floor where it is located, the square footage, the number of windows, and the size of each window. (Example: Bedroom #2: Basement, 10ft. x 7ft., 2 windows, window #1: 24in. x 24in., window #2: 48 in x 48 in)
Total number of bathrooms in the dwelling
For each bathroom, provide the floor location, square footage, shower (yes or no), if yes any handheld attachment locations, bathtub (yes or no), if yes any handheld attachment locations, call cord (yes or no), and a description of other safety features. (Example: Bathroom #5: Second Floor, 5ft. x 5ft., shower (yes), shower arm diverter, bathtub (no), call cord (no) other safety features: shower is curbless, has grab bars, and a bench)
How many residents are expected to have vehicles parked at or near the dwelling?
Terms and Conditions
By typing my name in the boxes below, I agree that I'm electronically signing this form. I affirm that the information that I've provided is accurate and true to the best of my knowledge. I understand that my electronic signature is legally binding and equivalent to my handwritten signature.
Name:

First NameLast Name
Date

MonthDayYear
Hour MinutesAM/PM Option
Filer Email
example@example.com
Should be Empty:

Reasonable Accommodations Form

Applicant Information

Disability Status

Property Information

Filing For Information

The Accommodation Request

Occupancy and Dwelling Details

Terms and Conditions