Free Request for Accommodations - Michigan

Approved, SCAO

Court name and location REQUEST FOR ACCOMMODATIONS

Today's date

Instructions for completing form: Provide your name, address, and telephone number. Check the boxes which apply to you and provide any necessary details. When you have completed this request, please return it to the court at the above address.

1. Name

Address

City

State

Zip

Telephone no.

2. Court activity you need accommodations for: Hearing
Date

Mediation meeting
Date

Jury duty
Date(s)

Other (specify):
include dates if relevant

3. What is the nature of your disability? Physical mobility impairment (wheelchair, walker, crutches, etc.) Speech impairment (specify): Visual impairment Hearing impairment (specify) Other (specify): 4. What type of accommodation are you requesting? Interpreter for deaf (specify whether ASL, tactile, oral, etc.) Assistive listening device (specify type of device) Physical location accessible for persons with a physical mobility concern. Other (specify)
For court use only

deaf

hard of hearing

MC 70 (10/97)

REQUEST FOR ACCOMMODATIONS