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Request for Reasonable Accommodation 1. Case No: Date: Case Name: 2. Name of Person Requesting: Address: Phone No.: (Mailing Address) (Area Code, Phone Number) E-mail: (City, State, Zip Code) 3. I am participating in a court proceeding/activity as a (check all that apply): Petitioner/Plaintiff Defendant/Respondent Attorney Witness Juror Judicial Officer Other (specify interest in or connection to proceeding, if any) . 4. List all known dates/times the accommodation(s) are needed (specify): 5. Why is an accommodation needed? . 6. What accommodation would you like? And why? . 7. Please provide any information that would help the court respond to your request. . 8. How do you want to be informed of the status of your request for accommodation? Phone Writing E-mail In person Other (specify): ---PAGE BREAK--- Date: (Signature of Person Requesting) (Print Name of Person Requesting)