INSTRUCTIONS: To enable a person with a disability to access the court system, information is
needed to determine the nature and extent of any requested accommodation. It is the policy of the
MA Trial Court to process all reasonable accommodation requests within 72 hours of the date the
request is received.
Massachusetts Trial Court
Request for
Reasonable Accommodation
MA Trial Court
Office of Court Management
2 Center Plaza
Suite 540
Boston, MA 02108
Submit form to: The ADA Coordinator in the courthouse where you are seeking an accommodation.
Refer to website for directory of ADA Coordinators at http://www.mass.gov/courts/admin/hr.html for contact information. This document
may be available in alternative format.
I wish to make a Request for a Reasonable Accommodation:
Date of Request
Name:
Phone:
E-mail:
Address:
(Street) (City) (State) (Zip)
Other Status (Specify)
Name of Court
Court Appearance:
Date of Appearance
Case Name and Docket#
Access:
Issue-Related:
Type of Accomodation Requested
physical access to parking lots/entrances/rest rooms/elevators/court rooms.
I need the following reasonable accommodations:
Date and Time Needed
at
AM
PM
Limitations Requiring Accommodation:
Signature of Requestor or Person completing the form
Relationship to Requestor
Status
Juror Party
Witness
Attorney/Legal Staff
Large Print
Digital Audio Reading
Sign Language Interpreter
CA
RT (Communication Access Real-time Translation)
Assistive Listening Devices
Other (please specify)
