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Morgan County Planning & Development P.O. Box 1357 150 East Washington Street, Suite 200 Madison, Georgia 30650 (706) 342-4373 Office (706) 343-6455 Fax ADA Request for Accommodation Please print legibly. Reporting Individual: Date of Request: Address: City, State and Zip: Telephone Number: Business Phone: Other Contact Information: If person needing accommodation is not the individual completing this form, please complete below: Name: Telephone Number: Other Contact Information: Check One: Accommodation Barrier Removal Accommodation needed or location of barrier: Brief statement of why the accommodation is needed or the barrier removed: Date accommodation is needed Signature: Date: Planning and Development Representative: Date: