UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA APPLICATION FOR ACCOMMODATIONS FOR TRIAL PARTICIPANTS WITH COMMUNICATION DISABILITIES, JURORS, AND MEMBERS OF THE PUBLIC (SUBMIT APPLICATION A MINIMUM OF TEN (10) COURT DAYS PRIOR TO A SCHEDULED COURT PROCEEDING; IF SUBMITTING BY U.S. MAIL, SUBMIT A MINIMUM OF FIFTEEN (15) COURT DAYS PRIOR TO SCHEDULED COURT PROCEEDING) CASE NAME: CASE NO: JUDGE: APPLICANT'S NAME:APPLICANT'S ROLE: PARTY WITNESS ATTORNEY JUROR OTHER - SPECIFY:If applicant has checked 223other224 for applicant222s role, include a detailed explanation of the case-related interest in the court proceeding for which the accommodation is sought:Applicant222s Contact Information: G-122 (04/18)APPLICATION FOR ACCOMMODATIONS FOR TRIAL PARTICIPANTS WITH COMMUNICATIONS DISABILITIES, JURORS, AND MEMBERS OF THE PUBLICPage 1 of 3 ADDRESS: CITY: STATE: ZIP CODE: EMAIL: PHONE NUMBER: In accordance with the local guidelines of this court, application is made for court- provided sign language interpreters and/or other appropriate auxiliary aids as follows: Equipment for the hearing impaired CART (Communications Access Realtime Translation) Sign language interpreter Other communication/auxiliary aid or services, as specified: Note: If specific auxiliary aids and services are requested, alternative auxiliary aids and services must be identified here by the requesting participant in case the primary auxiliary aids and services requested are unavailable, incompatible with the courtroom, or too expensive. Type of court proceeding or activity for which auxiliary aids and services are requested: Proceeding Date/Time/Courtroom No.: Note: Application should be made as far in advance of the requested implementation date as possible. Description of the communication disability that necessitates the auxiliary aids and services (attach pages if necessary): G-122 (04/18)APPLICATION FOR ACCOMMODATIONS FOR TRIAL PARTICIPANTS WITH COMMUNICATIONS DISABILITIES, JURORS, AND MEMBERS OF THE PUBLICPage 2 of 3 If physical accommodations are necessary, this application will be forwarded to the ADA Officer designated by the General Services Administration to properly process and provide the necessary accommodations. Provide a description of the physical accommodations requested and a description of the disability that necessitates the accommodations: If the communications disability is not obvious, you may attach documentation from an appropriate health care or rehabilitation professional that is sufficient to substantiate the disability and the need for the auxiliary aids and services requested. Documentation is sufficient if it: (1) describes the nature, severity, and duration of the applicant222s communication disability, the activity or activities that the disability limits, and the extent to which the disability limits the applicant222s ability to perform the activity or activities; and (2) substantiates why the requested auxiliary aids and services are needed. Check the applicable options below and sign and date application where indicated: I certify under penalty of perjury that I am deaf, hearing impaired, or have other communication disabilities that render me eligible for receipt of these auxiliary aids and services; and/or I certify under penalty of perjury that I require the physical accommodation(s) requested above. Applicant's Signature: Date:Submit application by one of the following: (1) U.S. mail or personal delivery to: Access Coordinator, Interpreter Services Department, U.S. Courthouse, Western Division, 350 West 1st Street, Suite 4311, Los Angeles, California 90012-4565; or (2) electronic mail to: AccessCoordinator@cacd.uscourts.gov; or (3) facsimile transmission to: Access Coordinator at (213) 894-5483.G-122 (04/18)APPLICATION FOR ACCOMMODATIONS FOR TRIAL PARTICIPANTS WITH COMMUNICATIONS DISABILITIES, JURORS, AND MEMBERS OF THE PUBLICPage 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com