Fill and Sign the Mc 410 Applicants Informationto Be Kept Confidential

APPLICANT'S INFORMATION TO BE KEPT CONFIDENTIAL MC-410APPLICANT (name): FOR COURT USE ONLYAPPLICANT isWitness JurorAttorney PartyOther(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 ANDApplicant requests accommodation under rule 989.3 of the California Rules of Court, as follows:1. Type of proceeding: Criminal Civil2. 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)RESPONSEThe 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 wholecreates an undue burden on the courtrequested 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 appearanceFrom (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 1.100MC-410 [Rev. January 1, 2007] REQUEST FOR ACCOMMODATIONS BY PERSONS WITH DISABILITIES AND RESPONSE electronic form  2005-7 WWW.LawCA.com Law Publishers