Language Access Request | Elm City Communities

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Questions or Assistance

If you need this document in a different language or LARGER FONT or if you need a reasonable accommodation (persons with disabilities), please call 203-498-8800 ext. 1507. Advance notice of seven days is required in order to arrange for interpreter services.

Fraud and False Statements: Title 18, Section 1001 of the U.S. Code states that a person who knowingly and willingly makes false and fraudulent statements to any department or employee of the United States Government, HUD, a Public Housing Authority or a property owner may be subject to penalties that include fines and/or imprisonment.

Language Access Request Form

I am:*
- HCV Participant or Applicant
- LIPH resident
- 360 Management resident
Name (Head of Household)*
Prefix First Last Suffix
Primary Home Address*
Street Address City State ZIP
Phone*
Email
Service(s) Requested?
- Written Translation
- In-Person Interpretation
- American Sign-Language
Primary Language
Note: The household member requesting the accommodation(s) must meet HUD’s definition of Limited English Proficiency.
Written Translations
Please attach the document(s) that require translation along with this form.
Max. file size: 64 MB.
In-Person Interpretation
For in-person interpretation or American Sign Language, please provide the following information:
Type of Meeting
Please choose one
- 1:1 Meeting (recertification, hearing, etc.)
- Group Meeting
Language
Start Time

: Hour

Min

AM/PM
End Time

: Hour

Min

AM/PM
Meeting Location Address
Street Address or Name of Property Location (Community Room, Conference Room, Auditorium, etc.) City State ZIP / Postal Code
Program
Group Meeting or Event Information
Number of individuals attending with a Limited English Proficiency Total number of individuals attending the meeting On-site contact email Phone number

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