☐
COURT OF APPEALS ☐ COURT OF SPECIAL APPEALS
☐ CIRCUIT COURT ☐ DISTRICT COURT OF MARYLAND FOR
Located at
STATE OF MARYLAND
or Case No.
REQUEST FOR ACCOMMODATION FOR PERSON WITH DISABILITY
Requests for accommodation should be submitted to the court not less than thirty (30) days before the
proceeding for which the accommodation is requested.
Name of person needing accommodation:
Name of person requesting accommodation (if different person):
Person needing accommodation is: ☐ Party ☐ Witness ☐ Juror ☐ Prospective Juror ☐ Attorney
☐ Victim ☐ Victim’s Representative ☐ Other (Specify):
Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows:
1. Type of court proceeding:
☐ Criminal ☐ Civil ☐ Traffic ☐ Juvenile ☐ Family ☐ Other (Specify):
2. Hearing/Trial date (if any): Time:
3. Nature of disability or impairment (specify):
4. Type of accommodation(s) requested. Be specific.
NOTE: If requesting a sign language interpreter, specify type: American Sign Language interpreter (ASL),
Certified Deaf Interpreter (CDI), or Communication Access Real Time Translation (CART). If requesting a
spoken language interpreter, please use form CC-DC-041.
Please provide any further information that may assist the court in providing a reasonable
accommodation (specify):
☐ I request that this information be kept confidential to the extent allowed by law.
I certify that to the best of my knowledge this information is true and correct. I agree to provide medical
documentation if required by the court.
The clerks’s office and the ADA Coordinator are available to provide further assistance.
CC-DC-049 (Rev. 07/2021)
MRSPA
Requests for accommodation should be submitted to the court not less than thirty (30) days
before the proceeding for which the accommodation is requested. Specific case-related questions
(e.g. postponements) should not be made on this form.
Date Signature of Applicant/Applicant’s Representative
Attorney Number
