Request For Reasonable Accommodation For Disability
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Request For Reasonable Accommodation For Disability Form. This is a Arizona form and can be use in Pima Local County.
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Tags: Request For Reasonable Accommodation For Disability, Arizona Local County, Pima
Name:
Address:
City, State, Zip:
Phone:
Comp. # (if applicable):
ARIZONA SUPERIOR COURT, PIMA COUNTY
In the Matter of
Date of Birth:
Case Number:
REQUEST FOR REASONABLE
ACCOMMODATION FOR DISABILITY
1. I, _____________________________, request reasonable accommodation by the Court
for my disability.
2. My relationship to this case is I am the: ________________________________________.
3. My disability first arose on or about _____ / _____ / ____ and consists of: _____________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. I request the following form(s) of specific, reasonable, and necessary accommodation:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
The undersigned swear or affirm that the statements set forth above are true and correct, subject
to the penalties of making a false affidavit or declaration.
Date: ___________________
________________________________
Signature of Requesting Party
Copies mailed this date to:
Assigned Division
Court ADA Coordinator
Parties
1 of 1
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