Americans with Disabilities Act (ADA) Accommodation Request Form Instructions: Please fill out all sections of this form. To save this form with the intention of finishing it later, go to File, Save As. Then, select the location on your computer where you would like to save this form. Any data you entered will be saved with the form. When finished, mail, fax or deliver the completed 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. Please submit your completed form at least 10 business days prior to the date you need an accommodation, if at all possible. Date submitted Date(s) accommodation is needed Court location where accommodation is needed Case name or court file number (if known) Name of person needing an accommodation Address (number, street, apartment, city, state, zip code) Telephone number Email (optional) Person is: Juror Criminal Defendant Civil Plaintiff Family Witness Juvenile Other (Specify):____________ Type of Case: Conciliation Other (Specify):____________ I. What specific accommodation(s) are you requesting? II. Please provide any additional information that might be useful in reviewing your accommodation request. Form completed by: Self Other (print name):______________________________________________ For an electronic version of this form, please visit www.mncourts.gov. American LegalNet, Inc. www.FormsWorkFlow.com