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ADA Accommodation Request GF-153 - Wisconsin
| ADA Accommodation Request Form. This is a Wisconsin form and can be used in General Circuit Court Statewide . |
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For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY ADA Accommodation Request Case No. (if any) 1. Name of Person Requesting Accommodation E-mail Address Address Telephone/TTY Number Date Request Submitted 2. The person who needs the accommodation is a party. witness. juror. Other: attorney. 3. The accommodation will be needed on [Date] at [Time] for all proceedings related to this case. 4. The accommodation needed is Wheelchair space American Sign Language (ASL) interpreter(s) Other sign language interpreter(s) [Specify] Oral interpreter Realtime (videotext) translation Assistive listening device Large print/enlarged materials Breaks for medical reasons [State reason/frequency] Other: [Specify] a.m. p.m. (Complete the following, if different from #1 above.) 5. Name of person completing this form: Telephone/TTY Number: Mailing Address: E-mail Address: APPROVAL This accommodation request is approved. This accommodation request is denied because: BY: Court Official/Court ADA Coordinator DISTRIBUTION: 1. Judge 2. Clerk of Court 3. Attorney/party 4. Other: _________________________ GF-153, 03/12 ADA Accommodation Request Name Printed or Typed Date Title II, Americans with Disabilities Act and ADA Amendments Act, 42 USC §§12101-12213, §§46.295, 756.02, 756.001(3), 756.03(1), 885.38, and 905.015, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material.
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