UNITED STATES BANKRUPTCY COURT Western District of New York APPLICATION TO PROVIDE SERVICES TO THE HEARING-IMPAIRED OR OTHER PERSONS WITH COMMUNICATION DISABILITIES In re: ______________________________________________________ Case No. ________________ In accordance with guidelines of this Court, application is made for Court-provided sign language interpreter and/or other appropriate auxiliary aides as follows: G Sign language interpreter G Other communication/auxiliary aid, as specified: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ For the following hearing before Judge ______________________________________________ Hearing Date/Time/Location ______________________________________________________ G Debtor G Defendant G Witness Applicant’s Role: G Plaintiff G Other - specify: __________________________ I certify under penalty of perjury that I am hearing impaired, deaf, or have other communication disabilities that render me eligible for receipt of these services. Date: ____________________ ____________________________________________ Applicant’s Signature This application must be filed with the Access Coordinator in the Clerk’s Office at least three weeks before the date of the hearing. Melissa L. Frieday U.S. Bankruptcy Court, NY-W Olympic Towers 300 Pearl Street, Suite 250 Buffalo, NY 14202 (716) 362-3242 INTERNAL GUIDELINES FOR PROVIDING SERVICES TO THE HEARING IMPAIRED AND American LegalNet, Inc. www.FormsWorkflow.com