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Click ‘Get Form’ to open the HRA-102 form in the editor.
Begin by filling out Section I, which includes your name, case number, social security number, telephone number, mailing address, and any known HRA program/service details. Ensure all information is printed clearly.
Move to Section II to detail the reasonable accommodations you wish to appeal. Describe each denied accommodation and its denial date. You can attach additional sheets if necessary.
Explain why you believe the HRA's decision was incorrect in the provided space.
Indicate whether you were offered an alternative accommodation by checking the appropriate box and providing an explanation if you do not accept it.
Sign and date the form at the bottom. If applicable, have your authorized representative sign as well.
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