Accessibility Modification-Request for Reimbursement

Before filling out this form, please be sure you have uploaded your completed Accessibility Modification Plan and Request Modification Reimbursement form and the invoices for the modifications into the DAIL Housing Portal.

The form below will notify the DAIL Shared Living Portal Workgroup that you have uploaded the necessary documents into the DAIL Housing Portal and it is ready for DAIL to review.

For additional information about the DAIL Housing Accessibility Modification Reimbursement process and forms please use this link: DAIL Housing Accessibility Modification Reimbursement.

Fields marked with a red star * are a required field.

Your Name

Your Email Address

Your Phone Number

When entering your phone number please include the Area Code. List your phone number in the following way: 802-123-4567.

Provider Agency

Accessibility Assessment AID Number

Shared Living Provider Home Address

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