Free Application for Services to Persons with Communication Disabilities - Louisiana

UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF LOUISIANA

In Re:

Case No.:

APPLICATION for Services to Persons with Communication Disabilities In accordance with the local procedures of this Court, application is made for Court provided sign language interpreters or other appropriate auxiliary aids as follows: ( ) Sign language interpreter ( ) Other auxiliary aid, as specified:_______________________________________ _________________________________________________________________ _________________________________________________________________ for the following hearing before the Court: Hearing Date / Time / Location: _________________________________________ _________________________________________ Applicant Role: ( ) Debtor ( ) Defendant ( ) Plaintiff ( ) Witness

( ) Other {specify: ____________________ } I certify that I am deaf or hearing impaired and a qualified individual with a disability who meets the essential eligibility requirements for the receipt of services, or the participation in programs or activities provided by a public entity. Date: __________________ ____________________________ Applicant Signature