Page 1 of 2 Type of caseREQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES JD-ES-264 Rev. 4-19STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov Person is SignatureInstructions: Please do not submit this form using E-Services. E-filed forms may become part of the public file. Fill out all of the sections of this form. Send the filled out form to the Americans with Disabilities Act (ADA) contact person at the court location where the case will be heard. Additional documents may be attached, if necessary. ADA Notice The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at https://jud.ct.gov/ADA/towns.htm Name of person requesting accommodation Telephone number Date(s) accommodation is needed Address (number, street, apartment, town, state, zip code) Case name or docket number (if known) Location where accommodation is needed E-mail (optional) Juror Defendant Plaintiff Witness Other (specify): Criminal Civil Other (specify): I. Describe the nature of the disability that makes an accommodation necessary:II. Describe how the disability affects a major life activity:III. Suggest the reasonable accommodation that is necessary:IV. Special requests or additional comments: Date Family Juvenile American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2JD-ES-264 Rev. 4-19The request for accommodation is Granted.The request for accommodation is Granted with the following alternate accommodation:The request for accommodation is Denied.The applicant is not a qualified individual with a disabilityThe requested modification would cause a fundamental alteration of a program or serviceThe requested modification would present an undue financial or administrative burdenOther (specify):The applicant has been informed of the option to file a grievance / complaint.The applicant has been informed of the option to pursue other state or federal agency relief. Americans with Disabilities Act Division Coordinator or Designee **Signature required in cases of denial** Date The request for accommodation is Granted in part, denied in part. American LegalNet, Inc. www.FormsWorkFlow.com