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

Form JD-ES-264 is a Connecticut Judicial Branch form also known as the "Request For Accommodation By Persons With Disabilities". The latest edition of the form was released in March 1, 2018 and is available for digital filing.

Download an up-to-date Form JD-ES-264 in PDF-format down below or look it up on the Connecticut Judicial Branch Forms website.

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STATE OF CONNECTICUT
REQUEST FOR ACCOMMODATION
JUDICIAL BRANCH
BY PERSONS WITH DISABILITIES
www.jud.ct.gov
JD-ES-264 Rev. 3-18
Instructions:
Please do not submit this form using E-Services.
Fill out all of the sections of this form. Send the filled out form to the Americans with Disabilities Act 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
Criminal
Civil
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 www.jud.ct.gov/ADA/
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. 3-18
Instructions:
Please do not submit this form using E-Services.
Fill out all of the sections of this form. Send the filled out form to the Americans with Disabilities Act 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
Criminal
Civil
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 www.jud.ct.gov/ADA/
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. 3-18
Page 2 of 2
Print Form
Reset Form

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

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