UNITED STATES DISTRICT COURT DISTRICT OF MONTANAAPPLICATION FOR ACCOMMODATIONS FOR TRIAL PARTICIPANTS WITHCOMMUNICATION DISABILITIES (SUBMIT APPLICATION A MINIMUM OF TEN (10) COURT DAYS PRIOR TO ASCHEDULED COURT PROCEEDING; IF SUBMITTING BY U.S. MAIL SUBMIT AMINIMUM OF FIFTEEN (15) COURT DAYS PRIOR TO SCHEDULED COURTPROCEEDING) CASE NAME: CASE NO: JUDGE: LOCATION: APPLICANT222S NAME: APPLICANT ROLE:PARTYWITNESSATTORNEY OTHER-SPECIFY:If applicant has checked 223other224 for applicant222s role include a detailed explanation of thecase-related interest in the court proceeding for which the accommodation is sought:Applicant222s contact information: 1 American LegalNet, Inc. www.FormsWorkFlow.com In accordance with the local guidelines of this court, application is made for court providedsign language interpreters and/or other appropriate auxiliary aids as follows: Hearing impaired equipmentCART (Communications Access Realtime Translation)Sign language interpreter Other communication/auxiliary aid or services, as specified: Note:If specific auxiliary aids and services are requested, alternative auxiliary aids andservices must be identified here by the requesting participant in case the primaryauxiliary aids and services requested are unavailable, incompatible with the courtroomor too expensive.Type of court proceeding or activity for which auxiliary aids and services is requested:Proceeding date/time: Note:Application should be made as far in advance of the requested implementation dateas possible. Description of the communication disability that necessitates the auxiliary aids and services(attach pages if necessary):2 American LegalNet, Inc. www.FormsWorkFlow.com If physical accommodations are necessary this application will be forwarded to the ADAofficer designated by the General Services Administration to properly process and providethe necessary accommodations. Provide a description of the physical accommodationsrequested and a description of the disability that necessitates the accommodations:If the communications disability is not obvious you may attach documentation from anappropriate healthcare or rehabilitation professional that is sufficient to substantiate thedisability and the need for the auxiliary aids and services requested. Documentation issufficient if it: (1) describes the nature, severity, and duration of the applicant222scommunication disability, the activity or activities that the disability limits, and the extentto which the disability limits the applicant222s ability to perform the activity or activities; and(2) substantiates why the requested auxiliary aids and services are needed.Check the applicable options below and sign and date application where indicated:I certify under penalty of perjury that I am deaf, hearing impaired, or have othercommunication disabilities that render me eligible for receipt of these auxiliary aidsand services; and/orI certify under penalty of perjury that I require the physical accommodation(s)requested above. Date: Applicant's Signature: Submit application by either:(1)U.S. mail or personal delivery to: Beth Conley, Chief Deputy, RussellE. Smith Courthouse, 210 East Broadway, Missoula MT 59801; or(2)electronic mail to: BethConley@mtd.uscourts.gov; or (3)facsimile transmission to: Beth Conley at (406) 542-7272.3 American LegalNet, Inc. www.FormsWorkFlow.com