I, verify that I am the owner of the home at the

following address (address at which home modification is planned):

I give my permission for Actions Completed Through Service-TN to construct a

wheelchair ramp and/or make other necessary modifications to the home at the address

above in order to accommodate individual(s) with disabilities. I further acknowledge that

upkeep and maintenance of the modification is not the responsibility of Actions Completed Through Service-TN.