GF-153, 05/19 ADA Accommodation Request Title II, Americans with Disabilities Act and ADA Amendments Act, 42 USC 24724712101-12213, 24724746.295, 756.02, 756.001(3), 756.03(1), 885.38, and 905.015, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY ADA Accommodation Request Case No. (if any) 1. Name of Person Requesting Accommodation E - mail Address Address Telephone/TTY Number Date Request Submitted 2. The person who needs the accommodation is a party. witness. juror. attorney. Other: 3. The accommodation will be needed on [Date] at [Time] a.m. p.m. for all proceedings related to this case. 4. The accommodation requested is Wheelchair space American Sign Language (ASL) interpreter(s) Other sign language interpreter(s) [Specify] Oral interpreter Realtime (videotext) translation Assistive listening device Large print/enlarged materials Breaks for medical reasons [State reason/frequency] Other : [Specify] (Complete the following, if different from #1 above.) 5. Name of person completing this form: Telephone/TTY Number: E - mail Address: Mailing Address: APPROVAL This accommodation request is approved . This accommodation request is denied because: BY: DISTRIBUTION: 1. Judge 2. Clerk of Court 3. Attorney /P arty 4. Other: Court Official/Court ADA Coordinator Title (Print or Type Name if not eSigned) Date American LegalNet, Inc. www.FormsWorkFlow.com