Connecticut > Statewide > Administrative
Request For Accommodaction By Person With Disabilities JD-ES-264 - Connecticut
| Request For Accommodaction By Person With Disabilities Form. This is a Connecticut form and can be used in Administrative Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES JD-ES-264 New 1-10 STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov Instructions: Fill out all of the sections of this form. Send the filled out form to the Americans With Disabilities Act contact person at the court location where the case will be heard. Additional documents may be attached, if necessary. Telephone number Date(s) accommodation is needed Name of person requesting accommodation Address (number, street, apartment, town, state, zip code) Location where accommodation is needed Person is Type of case Case name or docket number (if known) Email (optional) Juror Defendant Criminal Plaintiff Civil Witness Other (Specify): Other (Specify): I. Describe the nature of the disability that makes an accommodation necessary II. Describe how the disability affects a major life activity III. Suggest the reasonable accommodation that is necessary IV. Special requests or additional comments Signature Date The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com The request for accommodation is Granted. The request for accommodation is Granted with the following alternate accommodation. The request for accomodation is Denied the applicant is not a qualified individual with a disability the requested modification would cause a fundamental alteration of a program or service the requested modification would present an undue financial or administrative burden other (specify) The applicant has been informed of the option to file a grievance / complaint. The applicant has been informed of the option to pursue other state or federal agency relief. Americans with Disabilities Act Division Coordinator or Designee **Signature required in cases of denial** Date JD-ES-264 (Back/page 2) New 1-10 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
