Free Request for Accommodation by Persons with Disabilities - Maryland

COURT OF APPEALS COURT OF SPECIAL APPEALS CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR
City/County

Located at
Court Address

STATE OF MARYLAND or vs.
Plaintiff/Petitioner

Case No.
Defendant/Respondent

REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES
Name of Applicant: Applicant is: Party

Other Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows: 1. Type of court proceeding: 2. Hearing/Trial date: 3. Nature of disability related impairment (specify): Criminal Civil Traffic Juvenile Time: Other:

Witness

Juror

Attorney

4. Type of accommodation(s) (be specific - a list of examples of accommodations is available at the clerk's office). If requesting sign language interpreter, specify type:

5. Please provide any further information that may assist the court in providing a reasonable accommodation (specify):

I request that this information be kept confidential to the extent allowed by law. I certify that to the best of my knowledge this information is true and correct. I agree to provide medical documentation if required by the court.
Date Signature of Applicant/Applicant's Representative

Applicant/Applicant's Representative's Address

Telephone No.

The clerk's office and the ADA Coordinator are available to provide further assistance.
The request for accommodation is GRANTED; or Alternate accommodation(s) GRANTED (specify): The request for accommodation is DENIED. Applicant does not qualify under the ADA. It fundamentally alters the nature of the service program or activity as defined by the ADA. It creates an undue burden on the court as defined by the ADA.
Judge/Administrative Official

Date

If you disagree with this decision, you can file a Grievance. (Form CC-DC 50 is available for this purpose.) CC-DC 49 (Rev. 9/2005)