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2. District Court Request for Accommodation
4. 1. Information about the court case or activity.
6. What is the Case Number?
8. What is the Case Name?
10. If there is no specifc case, what is the court activity?
12. 2. Information about the person requesting accommodation.
14. Are you the person in need of an accommodation?

    1. Yes
    2. No
16. What is your name and if applicable, the name of the person whom you are requesting accommodation?
18. 3. Describe the court proceeding or activity you need accommodation for, include the date, time and location.
20. 4. How are you participating in a court proceeding/activity (check all that apply):

    1. Party
    2. Juror
    3. Attorney

    1. Observer
    2. Witness
    3. Other
22. If other, please explain:
24. 5. Describe the disability for which you are requesting an accommodation.
26. 6. Describe what accommodation you are requesting and explain why this specific accommodation is necessary.
28. 7. Provide any information that you think would help the court respond to your request.
30. 8. Contact Information:
32. Email Address
34. Address
36. City
37. State
38. Zip Code
40. Phone Number
42. Other, please speficy.
44. What is the best way to notify you about the decision on your request?

    1. Email
    2. Mail
    3. Phone Call
    4. Other (see above)
46. Date
47. Signature
    Type Name of Person Requesting Accommodation
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field