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Request For Reasonable Accomodation - Minnesota

Request For Reasonable Accomodation Form. This is a Minnesota form and can be used in ADA District Court Dakota Local County .
 Fillable pdf Last Modified 2/20/2014
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REQUEST FOR REASONABLE ACCOMMODATION In compliance with Title II (Program Accessibility Requirements) of the Americans with Disabilities Act (ADA) Name: _____________________________________________ Address: ___________________________________ City/State: _______________ Zip: ______________ Home Phone: ____________________ Work Phone: _________________ Cell Phone: _______________ Check here if requesting on behalf of another Name: _____________________________________________ Address: ___________________________________ City/State: _______________ Zip: ______________ Home Phone: ____________________ Work Phone: _________________ Cell Phone: _______________ Description of accommodation requested. (Please be as specific as possible. Attach additional sheets if necessary.) Date Needed: County: ___________________ ___________________ Court File Number: __________________ Location: __________________ Suggested course of action by the court which the requester believes would best resolve the situation. Please provide as much information as possible: Requester Signature: _______________________________ Date: ________________________ Upon completion please submit form to the appropriate county Court Administrator (addresses listed below): Carver ­ Vicky Carlson McLeod ­ Karen Messner Dakota ­ Carol Renn Scott ­ Greg Ess Goodhue ­ Yvonne Black Sibley ­ Karen Messner Le Sueur ­ Joanne Kopet COURT USE ONLY Request Received: Action Taken: Final Outcome: ___ Accepted Request ___ Unable to Accept Request Reason: ___ Accepted Request with Modification Signature: ____________________________ Date: ____________________ American LegalNet, Inc. www.FormsWorkFlow.com County Courthouse Address Directory Carver County Court Administration Carver County Justice Center 604 E 4th St Chaska, MN 55318 Phone: 952-361-1420 Fax: 952-361-1491 Dakota County Court Administration Dakota County Judicial Center 1560 W Hwy 55 Hastings, MN 55033 Phone: 651-438-8100 Fax: 651-438-8160 Goodhue County Court Administration Goodhue County Justice Center 454 W 6th St Red Wing, MN 55066 Phone: 651-267-4800 Fax: 651-267-4989 McLeod County Court Administration McLeod County Courthouse 830 11th St E Glencoe, MN 55336 Phone: 320-864-5551 Fax: 320-864-5905 Scott County Court Administration Scott County Justice Center 200 Fourth Ave W Shakopee, MN 55379-1220 Phone: 952-496-8200 Fax: 952-496-8211 Sibley County Court Administration Sibley County Courthouse PO Box 867 400 Court Ave Gaylord, MN 55334 Phone: 507-237-4051 Fax: 507-237-4062 Le Sueur County Court Administration Le Sueur County Courthouse 88 S Park Ave Le Center, MN 5605 Phone: 507-357-8252 Fax: 507-357-6433 American LegalNet, Inc. www.FormsWorkFlow.com
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