Orange — Request for Accommodation to Pump or Express Breast Milk (MC-420)

Source: http://www.courts.ca.gov/documents/mc420.pdf

Request for Accommodation to MC-420 CONFIDENTIAL Pump or Express Breast Milk If you need break time while at court to pump or express breast milk, you may Clerk receives and date stamps here. use this form to make your request.

Try to make this request before the date you need the accommodation, if you can.

1 Your information Name: Court Name and Address: Address:

Phone:
Email:
Important! Provide complete and updated contact information. The
court may contact you about this request. The contact will only be
about this request, and you must not discuss the details of any court
case. Case Number (if you know it):

2 How are you participating in the case? Juror Party Witness Lawyer Case Name or Type (if you know it): Other (explain): 3 For which court event are you asking for break time? a. Date or dates: Department: Courthouse: b. Other (explain):

4 Explain your request a. At what times or how often are you asking for the breaks to happen? (specify):

b. How much break time are you asking for? (give length in minutes of each break):
c. Would you like to provide more information about your request? Yes (explain below) No

More information on this request is attached. (you may use form MC-025)
d. If the court has an available lactation room, would you like to use it? Yes No

Date:

Type or print your name Signature
Confidential—do not place in court file.

Judicial Council of California, courts.ca.gov New January 1, 2026, Optional Form Request for Accommodation to Pump or MC-420, Page 1 of 2 Gov. Code, § 69894.1 Express Breast Milk Cal. Rules of Court, rule 2.40

Case Number (if you know it):Name:

Court fills out below
(Optional)
Important! If your situation changes after you make this request and you do not need the break for the
date or dates you listed in 3 , please contact the court at:
Phone: Email:

Your request is GRANTED. The court will provide the accommodation requested. Your request is GRANTED IN PART. The reasons for denying part of your request are listed below. The court will provide the accommodation as follows:

Your request is DENIED for the reasons listed below. The court’s reasons for denying all or part of your request are:

The court will provide the accommodation: For the dates and times requested. For every court hearing in this case. On the following date or dates: More information on this decision is attached.

Date:

Type or print name Signature

The court responded in person, by phone, or by mail/email on:

Please note: Form MC-420 is a confidential form that is not part of the case file. The form must be given to the

ADA coordinator or designated person in your court. If you are submitting papers to the court electronically, you must not include form MC-420 with your filing.

You may be able to ask for a review of this decision. California Rules of Court, rule 2.40(f) explains how to do this. Confidential—do not place in court file.

New January 1, 2026 Request for Accommodation to Pump or MC-420, Page 2 of 2 Express Breast Milk For your protection and privacy, please press the Clear button after you have printed the form. Print Save Clear