Free Request For Accommodations - Maryland

REQUEST FOR ACCOMMODATIONS
Use this form to request accommodations or to file a complaint if your request for accommodations has not been satisfied.

Court Location: Name: Address: City/State: Date of Request for Accommodation/Complaint: ACCOMMODATION REQUESTED COMPLAINT Please print or type and be as specific as possible. (Use other side if necessary.) Zip Code: Telephone Number:

Signature: Have you filed a complaint with a Federal, State or Local Agency? If yes, indicate agency:

Date: Yes No

Please return to the local coordinator or Office of Fair Practices, Judiciary Education and Conference Center, 2003C Commerce Park Drive, Annapolis, Md. 21401. You will receive an initial response within 10 working days upon receipt of this document in our office. If you have any questions please call the Office of Fair Practices (410) 260-3661.

Signature of ADA Coordinator: Copy forwarded to Office of Fair Practices
DCA 92 (Rev. 2/2009)

Date:

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