Americans with Disabilities Act Accommodation (ADA) Title II Request for Reasonable Accommodation Form (Includes Request for Interpreter for Hearing/Speech Impaired)
Client Information - Section A
Name: _____ Phone: ☐ _____ Address: _____ Email: ☐ _____ Mobile: ☐ _____ Please place a check mark in the box for how you want to be informed of the status of your request. Please check the box that most describes your status in this matter: ☐ Plaintiff ☐ Defendant ☐ Parent ☐ Child ☐ Witness ☐ Attorney ☐ Victim ☐ Juror ☐ Other (please explain)
Requestor Information - (if different from above) - Section B
Name: _____ Bus.Phone/ Mobile: _____ Address: _____ Fax: _____ Email: _____ Relationship to Client: _____ TTY: _____
Accommodation - Section C
Accommodation Requested:
Location of Proceeding - Section D Proceeding Information (if known)
☐ Magisterial District Court No. _____ Case #: _____ District Judge Name: _____ Case Name: _____ ☐ Criminal Division ☐ Civil Division ☐ Orphans' Court Division Judge: _____ ☐ Family Division ☐ Adult ☐ Juvenile Proceeding Date: _____ Proceeding Time: _____ Specify Address: _____ Proceeding Type: _____
AFTER COMPLETING THE FORM, PLEASE SEND TO: COURT ADA COORDINATOR, 117 Baltimore Street, 4th Floor, Gettysburg, PA 17325 Phone: (717) 337-9846, Fax: (717) 334-8817, Email: courtadacoordinator@adamscountypa.gov
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 E
Service Provider Company: _____ Fax: _____ Individual Interpreter Name: _____ Email: _____ Date to: Provider Name: _____ Provider: _____ Bus. Phone Mobile: _____
Court Official Verification - Section F
Verifying Official Shall Maintain a Copy in the Court's Case File 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
Court Official: _____ Signature: _____ Title: _____ Date: _____
(08/14)