Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested. Specific case-related questions (e.g. postponements) should not be made on this form. COURT OF APPEALS COURT OF SPECIAL APPEALS CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR City/County Located at STATE OF MARYLAND or Plaintiff/Petitioner Court Address Case No. vs. Defendant/Respondent REQUEST FOR ACCOMMODATION FOR PERSON WITH DISABILITY Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested. Name of person needing accommodation: Name of person requesting accommodation (if different person): Prospective Juror Person needing accommodation is: Party Witness Juror Victim Victim's Representative Other (Specify): Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows: 1. Type of court proceeding: Other (Specify): Criminal Civil Traffic Juvenile Family 2. Hearing/Trial date (if any): 3. Nature of disability or impairment (specify): 4. Type of accommodation(s) requested. Be specific. Time: Attorney [Note - If requesting a sign language interpreter, specify type: American Sign Language interpreter (ASL), Certified Deaf Interpreter (CDI), or Communication Access Real Time Translation (CART). If requesting a spoken language interpreter, please use form CC-DC-041.] 5. Please provide any further information that may assist the court in providing a reasonable accommodation (specify): I request that this information be kept confidential to the extent allowed by law. I certify that to the best of my knowledge this information is true and correct. I agree to provide medical documentation if required by the court. Date Printed Name Signature of Applicant/Applicant's Representative Telephone Number Address Fax E-mail City, State, Zip The clerk's office and the ADA Coordinator are available to provide further assistance. The request for accommodation is GRANTED; or The request for accommodation is DENIED. Applicant does not qualify under the ADA. Alternate accommodation(s) GRANTED (specify): It would fundamentally alter the nature of the service, program, or activity under the ADA. It would create an undue burden on the court under the ADA. Date Judge/Administrative Official ID No. If you disagree with this decision, you can file a Grievance. (Form CC-DC-050 is available for this purpose.) CC-DC-049 (Rev. 03/2016) American LegalNet, Inc. www.FormsWorkFlow.com