Fill and Sign the Accommodations Disabilities Form

APPLICANT'S INFORMATION TO BE KEPT CONFIDENTIAL MC-410 APPLICANT (name): ––––– FOR COURT USE ONLY APPLICANT is Witness Juror Attorney Party Other (Specify) Person submitting request (name): ––––– APPLICANT'S ADDRESS: ––––– ––––– TELEPHONE NO.: ––––– NAME OF COURT: ––––– STREET ADDRESS: ––––– MAILING ADDRESS: ––––– CITY AND ZIP CODE: ––––– BRANCH NAME: ––––– JUDGE: ––––– CASE TITLE: ––––– DEPARTMENT: ––––– REQUEST FOR ACCOMMODATIONS BY PERSONS CASE NUMBER: WITH DISABILITIES RESPONSE ––––– AND Applicant requests accommodation under rule 989.3 of the California Rules of Court, as follows: 1. Type of proceeding: Criminal Civil 2. Proceedings to be covered(for example, bail hearing, preliminary hearing, trial, sentencing hearing, family, probate, juvenile): ––––– 3. Date or dates needed (specify): ––––– ––––– 4. Impairment necessitating accommodation (specify): ––––– ––––– 5. Typeor types of accommodation requested (specify): ––––– ––––– 6. Special requests or anticipated problems (specify): ––––– ––––– I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE) RESPONSE The accommodation request is GRANTED and The accommodation is DENIED because it the court will provide the fails to satisfy the requirements of rule989.3 requested accommodation, in whole creates an undue burden on the court requested accommodation, in part (specify below): ––––– fundamentally alters the nature of the service, alternative accommodation (specify below): program, or activity ––––– For the following reason (attach additional pages, if ––––– necessary): [See Cal. Rules of Court, rule 989.3(g), For the following duration: for the review procedure.] For the above matter or appearance From (dates): ––––– to ––––– Indefinite period Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE) SIGNATURE FOLLOWS THE LAST PAGE OF THE RESPONSE. Page 1 of 1 Form Approved for Optional Use Cal. Rules of Court, Judicial Council of California rule 1.100 MC-410 [Rev. January 1, 2007] REQUEST FOR ACCOMMODATIONS BY PERSONS WITH DISABILITIES AND RESPONSE electronic form ã 2005-7 WWW.LawCA.co m Law Publishers