Request ADA Accommodations

36th District Court
421 Madison Street
Detroit, MI 48226
LaDonn Banks, ADA Coordinator
Telephone: (313) 965-4065

DATE OF REQUEST (mm/dd/yyyy):*

DATE ACCOMMODATION NEEDED (mm/dd/yyyy):*

APPLICANT FIRST NAME:*

APPLICANT MIDDLE NAME:

APPLICANT LAST NAME:*

E–mail*

MAILING ADDRESS:*

CITY:*

STATE:*

ZIP CODE:*

TELEPHONE NUMBER (xxx-xxx-xxxx):*

CASE NUMBER (IF APPLICABLE)

TYPE OF COURT PROCEEDING, SERVICE, ACTIVITY, OR PROGRAM YOU ARE ATTENDING

NATURE OF DISABILITY:

TYPE OF ACCOMMODATION REQUESTED:

Type the code from the image