Alameda — The Request for Accommodations by Persons with Disabilities and Order form, MC 410 Form

Source: https://www.courts.ca.gov/documents/mc410.pdf

Disability Accommodation MC-410 CONFIDENTIAL Request

Clerk receives and date stamps here.

If you have a disability and need an accommodation while you are at court, you can use this form to make your request. For more information, see form MC-410-INFO . Make this request at least 5 days (when the court is open) before you need the accommodation. Court Name and Address: 1 Your information Name: Address:

Phone:
Email: Case Number (if you know it):

2 How are you involved in the case? Juror Party Witness Lawyer Case Name/Type (if you know it): Other (explain): 3 When and where do you need the accommodation? [date(s), time(s), and court location]

4 What accommodation do you need at the court?

5 Why do you need this accommodation to assist you in court?

More information on this request is attached.

Date:

Type or print name Signature (Optional) If a court employee, caregiver or other person helped fill out this form and is willing to provide more information if needed, provide contact information below: Name: Email: Phone:

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2021, Optional Form MC-410, Page 1 of 2 Cal. Rules of Court, rule 1.100 Disability Accommodation Request

Case Number (if you know it): Name: Court fills out below (Optional) Important! If your case is delayed or dismissed after you make this request and you do not need the accommodation for the date you specified under 3, please contact the court at: Phone: Email:

Your request is GRANTED. The court will provide the accommodation(s) requested.

Your request is DENIED IN WHOLE OR IN PART. The denied portion of your request: Does not meet the requirements of Cal. Rules of Court, rule 1.100 . Creates an undue financial or administrative burden for the court. Changes the basic nature of the court's service, program, or activity. Explain the reasons supporting the box(es) checked above:

Instead, the court will provide the following accommodation(s):

The court will provide the accommodation(s): For the date(s) and time(s) requested Indefinitely On date(s):

More information on this decision is attached.

Date:

Type or print name Signature The court responded in person, by phone, or mail/email on: Note: You may be able to ask for a review of this decision. Cal. Rules of Court, rule 1.100(g) explains how to do this.

Rev. January 1, 2021 MC-410, Page 2 of 2 Disability Accommodation Request

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