Approved, SCAO Court name and address REQUEST FOR REASONABLE ACCOMMODATIONS AND RESPONSE Telephone number of ADA coordinator: You should request accommodations as far as possible in advance of your court appearance or other court activity. To request accommodations, complete and return this form to the court at the above address. If you need help completing this form, contact the ADA coordinator at the above telephone number. To properly evaluate your request, the court may ask you for more information. The ADA coordinator will respond to your request before the court appearance or other court activity. If your request is denied, you may request a review in accordance with the court's local administrative order. At your request, the court will provide you a copy of the local administrative order. Today's date APPLICANT INFORMATION (to be kept confidential) Applicant is Witness Juror Attorney Party Other (specify) Case name and number (if applicable) Name Address City State Zip Telephone no. E-mail address 1. What type of proceeding or court service, activity, or program are you attending (i.e., hearing, jury duty, mediation meeting, trial)? 2. On what dates do you need accommodations? 3. For what impairment do you need accommodations (for a sign language interpreter, specify ASL, CDI, or CART)? 4. What type of accommodations do you need? RESPONSE TO REQUEST The request is GRANTED for the above matter or appearance, from in whole as follows: (specify the accommodations) to , for an indefinite period, in part. As consented to by the applicant, alternative accommodations are as follows: (specify the accommodations) The request is DENIED because the applicant is not a qualified individual with a disability under the ADA. the request creates an undue financial or administrative burden on the court (as defined by the ADA). the request fundamentally alters the nature of the service, program, or activity (as defined by the ADA). The basis for this denial is: (Specify on separate sheet if needed. Include alternative accommodations offered but rejected by the applicant.) The applicant was notified of the court's response by Date MC 70 (10/15) Name by phone by mail by e-mail in person . on MCL 393.501 et seq., 42 USC 12111 et seq. REQUEST FOR REASONABLE ACCOMMODATIONS AND RESPONSE American LegalNet, Inc. www.FormsWorkFlow.com