Please provide the location of the Court/Agency where the above described incident took place and thedate of the incident:State of Maryland JudiciaryAmericans with Disabilities ActGrievance FormName:Address:Case Number:What would you like to see happen?I request that this information be kept confidential to the extent allowed by law.This form should be submitted to the Fair Practices Department as soon as possible, but no later than120 calendar days after the alleged violation.I certify that to the best of my knowledge this information is true and correct.Type or Print NameDateSignatureCC-DC-050 (Rev. 09/2018)Fair Practices Department580 Taylor Ave., A-2Annapolis, Maryland 21401Office: 410-260-3679 Maryland Relay: 711Fax: 410-841-9849fairpractices@mdcourts.govPhone Number(s): Work Cell HomePlease describe the original ADA Accommodation requested and the reason for the request:Please describe the alleged discrimination which denied you the provision of services, activities, programs,or benefits with the Maryland Judiciary: American LegalNet, Inc. www.FormsWorkFlow.com