APPLICANT'S INFORMATION TO BE KEPT CONFIDENTIAL APPLICANT (name): APPLICANT is Witness Juror Attorney Party Person submitting request (name): APPLICANT'S ADDRESS: FOR COURT USE ONLY MC-410 Other (Specify) TELEPHONE NO.: NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: JUDGE: CASE TITLE: DEPARTMENT: CASE NUMBER: REQUEST FOR ACCOMMODATIONS BY PERSONS WITH DISABILITIES AND RESPONSE Applicant requests accommodation under rule 1.100 of the California Rules of Court, as follows: 1. Type of proceeding: Criminal Civil Other: 2. Proceedings to be covered (for example, bail hearing, preliminary hearing, trial, sentencing hearing, family, probate, juvenile): 3. Date or dates needed (specify): 4. Impairment necessitating accommodation (specify): 5. Type or types of accommodation requested (specify): 6. Special requests or anticipated problems (specify): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (TYPE OR PRINT NAME) (SIGNATURE) RESPONSE The accommodation request is GRANTED and the court will provide the requested accommodation, in whole requested accommodation, in part (specify below): For the following duration: For the above matter or appearance From (dates): Indefinite period to The accommodation is DENIED in whole or in part because it fails to satisfy the requirements of rule 1.100. creates an undue burden on the court. fundamentally alters the nature of the service, program, or activity. For the following reason (attach additional pages, if necessary): [See Cal. Rules of Court, rule 1.100(g), for the review procedure] The court will provide the alternative accommodation as follows: Date response delivered in person or sent to applicant: (TYPE OR PRINT NAME) (SIGNATURE) SIGNATURE FOLLOWS THE LAST PAGE OF THE RESPONSE. Page 1 of 1 Form Approved for Optional Use Judicial Council of California MC-410 [Rev. January 1, 2010] REQUEST FOR ACCOMMODATIONS BY PERSONS WITH DISABILITIES AND RESPONSE Cal. Rules of Court, rule 1.100 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com