Request For Accommodation
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Request For Accommodation Form. This is a Maryland form and can be use in District Court Statewide.
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Tags: Request For Accommodation, DCA 92, Maryland Statewide, District Court
REQUEST FOR ACCOMMODATIONS
Use this form to request accommodations or to file a complaint if your request for accommodations has not been satisfied.
Court Location:
Name:
Telephone Number:
Address:
City/State:
Zip Code:
Date of Request for Accommodation/Complaint:
ACCOMMODATION REQUESTED
COMPLAINT
Please print or type and be as specific as possible. (Use other side if necessary.)
Date:
Signature:
Have you filed a complaint with a Federal, State or Local Agency?
Yes
No
If yes, indicate agency:
Please return to the local coordinator or Office of Fair Practices, Judiciary Education and Conference Center, 2003C
Commerce Park Drive, Annapolis, Md. 21401. You will receive an initial response within 10 working days upon receipt
of this document in our office. If you have any questions please call the Office of Fair Practices (410) 260-3661.
Signature of ADA Coordinator:
Date:
Copy forwarded to Office of Fair Practices
DCA 92 (Rev. 2/2009)
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