Requested By:

 *

Requested By:

Requestor's Name:

Requestor's Phone Number:ext.

Requestor's Email:

Requestor's Address:

Requestor is: 

Requestor is:

Defendant

Witness

Juror

Attorney

Party

Other: If other, type text here.

If accommodation is for court case, specify case name and/or case number:

If accommodation is for court case, specify case name and/or case number:

Requestor asks for accommodation under Title II of the Americans with Disabilities Act, as follows:

1. Type of proceedings or court service, activity, or program:

1. Type of proceedings or court service, activity, or program:

Criminal

Civil

Other: If other, type text here.

2. Proceedings to be covered (e.g., trial, hearing, sentencing, or other court service, program, or activity):

2. Proceedings to be covered (e.g., trial, hearing, sentencing, or other court service, program, or activity):

3. Dates accommodation(s) needed:

3. Dates accommodation(s) needed:

4. Type of accommodation: 

4. Type of accommodation:

5. Reason for accommodation(s) Note: the Court may require documentation of the disability on professional letterhead and the documentation must originate from qualified evaluators: 

5. Reason for accommodation(s) Note: the Court may require documentation of the disability on professional letterhead and the documentation must originate from qualified evaluators:

6. Special requests or anticipated programs: 

6. Special requests or anticipated programs:

Requestor's Signature:

Requestor's Signature:

Date:

Date:

This form will be submitted to the Tempe Municipal Court upon completion. Upon receiving the form, the Court Management or designee will, as soon as reasonably possible, provide a response to the request for accommodation. Please contact the Court if assistance is needed in completing the form. Phone: (480) 350-8454 Email: court-inquiries@tempe.gov 

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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