FORM TO BE KEPT CONFIDENTIAL (if box checked)

APPLICANT (name):

FOR COURT USE ONLY

APPLICANT IS:    Witness   Juror    Attorney     Party     Other

Person submitting request (name):

APPLICANT'S ADDRESS:
TELEPHONE NO:

    NAME OF COURT:

 STREET ADDRESS:

 MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME: NAME OF JUDGE:

CASE NAME:

REQUEST FOR ACCOMMODATIONS BY PERSONS WITH

DISABILITIES and ORDER

CASE NUMBER:

Applicant requests accommodation under California Rules of Court, rule 989.3, as follows:

1. Type of proceeding:  Criminal Check Box Criminal   Civil Check Box Civil

2. Proceedings to be covered (e.g., bail hearing, preliminary hearing, particular witnesses at trial, sentencing hearing):

3.  Dates accommodations needed: (specify):

4. Impairment necessitating accommodations (specify):

5.  Type of accommodations (be specific):

6.  Special requests or anticipated problems (specify):

7.  I request that my identity

To be kept confidential check box  

be kept CONFIDENTIAL

Not to be kept confidential check box  

NOT be kept CONFIDENTIAL

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)

Applicant signature line_________________________________________________

(SIGNATURE OF APPLICANT)

 

ORDER

The request for accommodations is GRANTED because

 

The request for accommodations is DENIED because

 

the applicant satisfies the requirements of the rule.

 

 

 the applicant does not satisfy the requirements of the rule.

 

it does not create an undue burden on the court.

 

 

 it creates an undue burden on the court.

 

 it does not fundamentally alter the nature of the service, program or activity.

 

 it fundamentally alters the nature of the service, program, or activity.

 

 

 

 

(Specify):

Date:

_________________________________________________

JUDGE

Form Adopted by the
Judicial Council of California
MC-410 [New January 1, 1996]

REQUEST FOR ACCOMMODATIONS BY PERSONS
WITH DISABILITIES and ORDER

Cal. Rules of Court,
rule 989.3