Americans with Disabilities Accommodation Request
If you are seeking accommodations per the
Americans with Disabilities Act
please submit your request by filling out the following form:
Please enter the required information.
Case No:
Date:
Name of Person Requesting:
*
Case Name:
Mailing Address:
Phone No:
*
City, State, Zip:
Email:
*
I am participating in a court proceeding/activity as a (check all that apply):
Petitioner/Plaintiff
Defendant/Respondent
Attorney
Witness
Juror
Other (Specify interest in or connection to proceeding, if any)
What is the disability that limits one or more of your major life activities (e.g., walking, hearing, speaking, seeing, reading or writing)?
*
Character Limit: 250
Will this disability require special accommodations in order for you to conduct your business in the court?
*
Yes
No
If yes, please describe below the special accommodations needed and include written documentation supporting the accommodation that you are requesting.
Supporting documentation
must
comply with the following:
1) Be on official letterhead from a licensed or certified health professional appropriate for diagnosing and treating the disability;
2) Make a recommendation for the
specific
accommodations with current detailed documentation supporting the request;
3) Be dated within the last three years.
4) List all known dates/times the accommodation(s) are needed (specify):
Character Limit: 250
5) Why is an accommodation needed?
*
Character Limit: 250
6) What accommodation would you like? And why?
*
Character Limit: 250
7) Please provide any information that would help the court respond to your request:
Character Limit: 250
8) How do you want to be informed of the status of your request for accommodation?
*
Phone
Writing
Email
In-Person
Other (Specify)
Supplemental Documents
You may attach additional documents below. Choose the file you would like to upload from your computer using the "Choose a file" button. The file size must be 5 MB or less, and be of type .jpg, .png, or .pdf format. You may only submit three files at a time.
Choose a file…
I declare under penalty of perjury under the laws of the stats of Arizona that the foregoing is true and correct.
Date:
*
at
*
(City, State)
*
(Type or Print Name of Person Requesting)
*
(Signature of Person Requesting)