COURT OF APPEALS
COURT OF SPECIAL APPEALS
DISTRICT COURT OF MARYLAND FOR
STATE OF MARYLAND
Name of Applicant:
Applicant requests accommodation under Americans with Disabilities Act (ADA) as follows:
1. Type of court proceeding:
2. Hearing/Trial date:
3. Nature of disability related impairment (specify):
4. Type of accommodation(s) (be specific - a list of examples of accommodations is available at the
clerk's office). If requesting sign language interpreter, specify type:
5. Please provide any further information that may assist the court in providing a reasonable
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 clerk's office and the ADA Coordinator are available to provide further assistance.
Signature of Applicant/Applicant's Representative
Applicant/Applicant's Representative's Address
CC-DC 49 (Rev. 9/2005)
The request for accommodation is GRANTED; or
Alternate accommodation(s) GRANTED (specify):
If you disagree with this decision, you can file a Grievance. (Form CC-DC 50 is available for this purpose.)
The request for accommodation is DENIED.
Applicant does not qualify under the ADA.
It fundamentally alters the nature of the
service program or activity as defined by the
It creates an undue burden on the court as
defined by the ADA.
REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES