COURT OF APPEALS COURT OF SPECIAL APPEALS CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR City/County Located at Court Address STATE OF MARYLAND or Case No. vs. Defendant/Respondent Plaintiff/Petitioner REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES Name of Applicant: Applicant is: Party Witness Juror Attorney Other Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows: 1. Type of court proceeding: Criminal Civil 2. Hearing/Trial date: Traffic Juvenile Other: Time: 3. Nature of disability related impairment (specify): 4. Type of accommodation(s) (be specific - a list of examples of accommodations is available at the clerk's office). If requesting sign language interpreter, specify type: 5. Please provide any further information that may assist the court in providing a reasonable accommodation (specify): I request that this information be kept confidential to the extent allowed by law. I certify that to the best of my knowledge this information is true and correct. I agree to provide medical documentation if required by the court. Date Applicant/Applicant's Representative's Address Signature of Applicant/Applicant's Representative Telephone No. The clerk's office and the ADA Coordinator are available to provide further assistance. The request for accommodation is GRANTED; or Alternate accommodation(s) GRANTED (specify): Date The request for accommodation is DENIED. Applicant does not qualify under the ADA. It fundamentally alters the nature of the service program or activity as defined by the ADA. It creates an undue burden on the court as defined by the ADA. Judge/Administrative Official If you disagree with this decision, you can file a Grievance. (Form CC-DC 50 is available for this purpose.) CC-DC 49 (Rev. 9/2005) American LegalNet, Inc. www.USCourtForms.com