Form JD-ES-264 "Request for Accommodation by Persons With Disabilities" - Connecticut

What Is Form JD-ES-264?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-ES-264 by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-ES-264 "Request for Accommodation by Persons With Disabilities" - Connecticut

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STATE OF CONNECTICUT
REQUEST FOR ACCOMMODATION
JUDICIAL BRANCH
BY PERSONS WITH DISABILITIES
www.jud.ct.gov
JD-ES-264 Rev. 4-19
Instructions:
Please do not submit this form using E-Services. E-filed forms may become part of the public file.
Fill out all of the sections of this form. Send the filled out form to the Americans with Disabilities Act (ADA) contact
person at the court location where the case will be heard. Additional documents may be attached, if necessary.
Name of person requesting accommodation
Telephone number
Date(s) accommodation is needed
Address (number, street, apartment, town, state, zip code)
Case name or docket number (if known)
Location where accommodation is needed
E-mail (optional)
Person is
Juror
Defendant
Plaintiff
Witness
Other (specify):
Type of case
Civil
Criminal
Family
Juvenile
Other (specify):
I. Describe the nature of the disability that makes an accommodation necessary:
II. Describe how the disability affects a major life activity:
III. Suggest the reasonable accommodation that is necessary:
IV. Special requests or additional comments:
Date
Signature
ADA Notice
The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA).
If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA
contact person listed at https://jud.ct.gov/ADA/towns.htm
Print Form
Reset Form
Page 1 of 2
STATE OF CONNECTICUT
REQUEST FOR ACCOMMODATION
JUDICIAL BRANCH
BY PERSONS WITH DISABILITIES
www.jud.ct.gov
JD-ES-264 Rev. 4-19
Instructions:
Please do not submit this form using E-Services. E-filed forms may become part of the public file.
Fill out all of the sections of this form. Send the filled out form to the Americans with Disabilities Act (ADA) contact
person at the court location where the case will be heard. Additional documents may be attached, if necessary.
Name of person requesting accommodation
Telephone number
Date(s) accommodation is needed
Address (number, street, apartment, town, state, zip code)
Case name or docket number (if known)
Location where accommodation is needed
E-mail (optional)
Person is
Juror
Defendant
Plaintiff
Witness
Other (specify):
Type of case
Civil
Criminal
Family
Juvenile
Other (specify):
I. Describe the nature of the disability that makes an accommodation necessary:
II. Describe how the disability affects a major life activity:
III. Suggest the reasonable accommodation that is necessary:
IV. Special requests or additional comments:
Date
Signature
ADA Notice
The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA).
If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA
contact person listed at https://jud.ct.gov/ADA/towns.htm
Print Form
Reset Form
Page 1 of 2
The request for accommodation is Granted.
The request for accommodation is Granted with the following alternate accommodation:
The request for accommodation is Granted in part, denied in part.
The request for accommodation is Denied.
The applicant is not a qualified individual with a disability
The requested modification would cause a fundamental alteration of a program or service
The requested modification would present an undue financial or administrative burden
Other (specify):
The applicant has been informed of the option to file a grievance / complaint.
The applicant has been informed of the option to pursue other state or federal agency relief.
Americans with Disabilities Act Division Coordinator or Designee
Date
**Signature required in cases of denial**
JD-ES-264 Rev. 4-19
Page 2 of 2
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