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2. Information about the court case or activity

4. What is the Case Number? *
5. What is the Case Name? *
7. If there is no specific case, what is the court activity?*

11. Information about the Person Requesting Accommodation.

13. First Name*
14. Last Name*
16. Email*
17. Phone number where a message can be left.*
19. Street Address*
21. City*
22. State*
23. Zip*
25. What is the best way to notify you about the decision on your request?*

    1. Email
    2. Mail
    3. Phone Call
    4. Other
26. Please Specify*

30. Information describing the need for Accommodation

32. Describe the court proceeding or activity you need accommodation for. *
34. Date and Time that you will need the accommodation.*
    Date and Time that you will need the accommodation.

    Date and Time that you will need the accommodation.
35. What is the location you need the accommodation?*
37. How are you participating in a court proceeding/activity (check all that apply):*

    1. Party
    2. Attorney
    3. Witness
    4. Juror
    5. Observer
    6. Other
38. Please Describe*
40. Describe the disability for which you are requesting an accommodation. *
42. Describe what accommodation you are requesting and explain why this specific accommodation is necessary. *
44. Provide any information that you think would help the court respond to your request. *
48. I swear or affirm under penalty of perjury under the laws of the State of Washington that all of the information above is true.
50. Type your name here to E-Sign*
51. Todays Date*
    Todays Date

55. Yakima County Superior Court

    John Franklin, ADA Contact

    128 N. 2nd St., Room 314

    Yakima, WA 98901

    (509) 574-1796 or (509) 574-2710

    john.franklin@co.yakima.wa.us

56. Yakima County Pretrial Services

    Jennifer Wilcox, ADA Contact

    128 N. 2nd Street, Room 200

    Yakima, WA 98901

    (509) 574-1872

    jennifer.wilcox@co.yakima.wa.us

57. Yakima County Juvenile Court

    Jolene Pleasant, ADA Contact

    1728 Jerome Avenue

    Yakima, WA 98902

    (509) 574-2090 or 574-2050

    jolene.pleasant@co.yakima.wa.us

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61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field