Section 1 of 1 in this document
SUFFOLK COUNTY DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR REASONABLE ACCOMMODATION
Full Name
*
Full Address
Street Address
*
City
*
State
*
Zip
*
Phone Number
*
Email
*
Program Division
*
Choose One
Temporary Assistance
SNAP
Medicaid
Emergency Housing
HEAP
Employment
Other
The activity, program or service for which a reasonable accommodation is requested:
*
Date of request for reasonable accommodation:
Is your accommodation request time sensitive? If yes, please explain:
*
Accommodation Requested – Be as specific as possible, e.g. adaptive equipment, reader, interpreter:
*
Reason for Request – Be as specific as possible:
*
Request for Additional Information – Please provide any additional information that might be useful in processing your request (you may attach any supporting documentation to your request):
Attach File(s) - multiple files can be uploaded
ADA 6 Request for Reasonable Accommodation (Rev. 3/22)
disregard this