Accessibility Modification-Request for Reimbursement

The form below allows you to email the DAIL Shared Living Workgroup a notification that you have uploaded your request for an Accessibility Modification Reimbursement into the DAIL Housing Portal and is ready for DAIL's 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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Math Question
6 + 1 =

Solve this simple math problem and enter the result, example for 1+3, enter 4.