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Request For Accommodation By Persons With Disabilites DC 49 - Maryland

Request For Accommodation By Persons With Disabilites Form. This is a Maryland form and can be used in Accounting District Court Statewide .
 Fillable pdf Last Modified 1/23/2014
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Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested. Specific case-related questions (e.g. postponements) should not be made on this form. COURT OF APPEALS COURT OF SPECIAL APPEALS CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR City/County Located at STATE OF MARYLAND or Plaintiff/Petitioner Court Address Case No. vs. Defendant/Respondent REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES Requests for accommodation should be submitted to the court not less than thirty (30) days before the proceeding for which the accommodation is requested. Name of Applicant: Victim Party Witness Juror Attorney Family Member or Guardian of a Victim Other Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows: Applicant is: 1. Type of court proceeding: Criminal Civil Traffic 2. Hearing/Trial date: 3. Nature of disability related impairment (specify): 4. Type of accommodation(s) requested. Be specific: [Note - If requesting a sign language interpreter, specify type: American Sign Language interpreter (ASL), Certified Deaf Interpreter (CDI), or Communication Access Real Time Translation (CART). If requesting a spoken language interpreter, please use form CC-DC 41.] 5. Please provide any further information that may assist the court in providing a reasonable accommodation (specify): Juvenile Time: Other: 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. 12/2012) American LegalNet, Inc. www.FormsWorkFlow.com
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