RELEASE: By signing below, I acknowledge that I have carefully reviewed this Reasonable Accommodation/Modification Form, that the information contained therein is accurate, and that the reasonable accommodation/modification request as set forth in this Form is the exact request that I have made of the property or landlord. This consent is valid for 12 months. I hereby authorize the PPD or Provider identified above to answer the questions on the Form, to provide applicable additional information, and to discuss this request with the property manager or landlord, or their agent. As set forth on the form, I expressly acknowledge, that the community or landlord will not ask the PPD or Provider to discuss or provide specific medical history, medical condition, or diagnoses applicable to me or the person on whose behalf I am making this request and providing this release. I understand that I am permitted to revoke this authorization at any time and can do so by submitting a request in writing to the Person Assisting Request (PAR). I understand that if my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. I authorize the property or landlord, or their agent, to provide the information it/they obtain from the PPD or Provider to HUD, any state or local civil rights agency, or court in the event of a dispute related to my reasonable accommodation/modification request.