MC 70 (10/15) REQUEST FOR REASONABLE ACCOMMODATIONS AND RESPONSE
REQUEST FOR REASONABLE
ACCOMMODATIONS AND RESPONSE
MCL 393.501 et seq., 42 USC 12111 et seq.
You should request accommodations as far as possible in advance of your court appearance or other court activity. To request
accommodations, complete and return this form to the court at the above address. If you need help completing this form, contact
the ADA coordinator at the above telephone number. To properly evaluate your request, the court may ask you for more information.
The ADA coordinator will respond to your request before the court appearance or other court activity. If your request is denied, you
may request a review in accordance with the court's local administrative order. At your request, the court will provide you a copy of
the local administrative order.
APPLICANT INFORMATION (to be kept confidential)
Witness Juror Attorney Party Other
1. What type of proceeding or court service, activity, or program are you attending (i.e., hearing, jury duty, mediation meeting, trial)?
2. On what dates do you need accommodations?
3. For what impairment do you need accommodations (for a sign language interpreter, specify ASL, CDI, or CART)?
4. What type of accommodations do you need?
The request is GRANTED
for the above matter or appearance, from to , for an indefinite period,
in whole as follows: (specify the accommodations)
in part. As consented to by the applicant, alternative accommodations are as follows: (specify the accommodations)
The request is DENIED because
the applicant is not a qualified individual with a disability under the ADA.
the request creates an undue financial or administrative burden on the court (as defined by the ADA).
the request fundamentally alters the nature of the service, program, or activity (as defined by the ADA).
The basis for this denial is: (Specify on separate sheet if needed. Include alternative accommodations offered but rejected by the applicant.)
The applicant was notified of the court's response by phone by mail by e-mail in person on
Case name and number (if applicable)
Name E-mail address
City State Zip Telephone no.
RESPONSE TO REQUEST
Court name and address
Telephone number of ADA coordinator: