2. CIRCUIT COURT FOR PRINCE GEORGE'S COUNTY MARYLAND

   14735 Main Street, Upper Marlboro, Maryland 20772

4. 
5. REQUEST FOR ACCOMMODATION FOR PERSON WITH DISABILITY FORM

   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.

7. Case Number*
9. State of Maryland or Name of Plaintiff/Petitioner *

    

10. vs.
11. Name of Defendant/Respondent*
13. REQUEST FOR ACCOMMODATION FOR PERSON WITH DISABILITY

    Submit this form with the first document you file in the case, or 30 days before the next court date.

15. Name of person needing accommodation: *
17. Name of person requesting accommodation (if differetnt person)
19. Person needing accommodation is:*

    1. Party
    2. Witness

    1. Juror
    2. Prospective Juror

    1. Attorney
    2. Victim

    1. Victim's Representative
    2. **Other (specify):
21. **If response above is "Other", please specify:
23. Applicant requests accommodation under Americans with Disabilities Act (AD) as follows:
25. 1. Type of court proceeding:*

    1. Criminal
    2. Civil

    1. Juvenile
    2. Family

    1. Other (specify)
27. If response above is "Other", please specify:
29. 2. Hearing/Trial date (if any):
30. Time:
32. 3. Nature of disability or impairment (specify):*
34. 4. Type of accommodation(s) requested. Be specific.*
36. 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 Request for Spoken Language Interpreter Form.

38. Please provide any further information that may assist the court in providing a reasonable accommodation (specify):
40. Confidentiality Request (optional)

    1. I request that this information be kept confidential to the extent allowed by law.
42. 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.
44. Date*
    Date
46. First Name*
47. Last Name*
49. Address*
51. City*
52. State*
53. Zip Code*
55. Phone Number*
56. Fax Number
58. Email Address*
60. The Clerk's Office and the ADA Coordinator are available to provide further assistance.
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field