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District Court Request for Accommodation
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District Court Request for Accommodation
1. Information about the court case or activity.
What is the Case Number?
What is the Case Name?
If there is no specifc case, what is the court activity?
2. Information about the person requesting accommodation.
Are you the person in need of an accommodation?
Yes
No
What is your name and if applicable, the name of the person whom you are requesting accommodation?
3. Describe the court proceeding or activity you need accommodation for, include the date, time and location.
4. How are you participating in a court proceeding/activity (check all that apply):
Party
Juror
Attorney
Observer
Witness
Other
If other, please explain:
5. Describe the disability for which you are requesting an accommodation.
6. Describe what accommodation you are requesting and explain why this specific accommodation is necessary.
7. Provide any information that you think would help the court respond to your request.
8. Contact Information:
Email Address
Address
City
State
Zip Code
Phone Number
Other, please speficy.
What is the best way to notify you about the decision on your request?
Email
Mail
Phone Call
Other (see above)
Date
Signature
Type Name of Person Requesting Accommodation
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Email address
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