Clark County CourtsRequest for Reasonable Accommodation Section1 Case Number: Date: Case Name: Section 2 Person Requesting Accommodation: (Last Name, First Name) (Mailing Address) (Area Code, Phone Number) (City, State, Zip Code) (E-mail) Section 3 I am participating in a court proceeding/activity as a (check all that apply): Petitioner/Plaintiff Defendant/Respondent Attorney Witness Juror Judicial Officer Other (Specify interest in or connection to proceeding, if any): Section 4 List all known dates and times the accommodations are needed (specify): Section 5 Why is the accommodation needed? Section 6 What accommodation would you like and why? Section 7 Please provide any information that would help the court respond to your request. Section 8 How do you want to be informed of the status of your request for accommodation? Phone Writing E-mail In Person Other (Specify): Date: at (City, State) (Type or print name of person making request) (Signature of person making request) American LegalNet, Inc. www.FormsWorkFlow.com