Request For Reasonable Accommodation (ADA)

AMERICANS WITH DISABILITES ACT ACCOMMODATION (ADA) TITLE II REQUEST FOR REASONABLE ACCOMMODATION FORM (INCLUDES REQUEST FOR INTERPRETER FOR HEARING /SPEECH IMPAIRED) Requestor Information ­ Section A Name: Address: Phone: Email: Mobile: Please check the box that most closely describes your status in this matter: Attorney Program Participant Other (please explain) Requestor Information (if different from above) Name: Address: Relationship to Client: Bus. Phone/ Mobile: Fax: Email: TTY: Accommodation Nature of the disability for which an accommodation is requested: Accommodation requested: Location of AOPC Program/Activity Name of Office: Address: AOPC Program/Activity Information (if known) AOPC Program/ Activity: AOPC Contact: Date of Event: Program/Activity Type: Time of Event: AFTER COMPLETING THE FORM, PLEASE SEND TO: Mary Vilter, ADA Coordinator, AOPC, 1515 Market St, Suite 1414, Philadelphia, PA 19102 mary.vilter@pacourts.us, 215.560.6300 I hereby certify that an Americans with Disabilities Act accommodation is required in the above-captioned action on the date stated. Signature: Date: FOR OFFICIAL USE ONLY Service Provider Information - Section B A SERVICE REQUEST HAS BEEN MADE FOR THE CLIENT NAMED ABOVE. Service Provider Company: Individual Interpreter Name: Bus. Phone/ Mobile: Fax: Email: Date to Provider: Court Official Verification ­ Section C VERIFYING OFFICIAL SHALL MAINTAIN A COPY IN AOPC'S PROGRAM FILES AND PROVIDE THE ORIGINAL TO THE SERVICE PROVIDER FOR SUBMISSION WITH BILLING. I hereby verify that the services were performed by the provider in the above-captioned action on the date and time stated. Start Date & Time: End Date & Time: AOPC Official: (Please print name) Signature: Date: American LegalNet, Inc. www.FormsWorkFlow.com Title: