ADA Request Form Today's Date Applicant Alternate Attorney Complainant Juror Other Party Witness Your First Name Your Last Name Your Street Address or PO Box City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Your Zip Code Phone Number Email Address Accommodations Information Case Number (if applicable) Court Clerk of the Court Customer Service Center Round Valley Justice Court; St. Johns Justice Court Puerco (Sanders) Justice Court Chinle Justice Court Apache County Superior Court Type of Proceeding, Court Service, Activity or Program Civil Criminal Family Court Family Court/Settlement Only Justice Courts Juvenile Other Probate/Mental Health Tax Court Proceedings to be Covered Bail Hearing Other Court Service Program Activity Particular Witness at Trial Preliminary Hearing Sentencing Hearing Trial Start Date Accommodations Needed (mm/dd/yyyy) End Date Accommodations Needed (mm/dd/yyyy) Type of Accommodations (please specify) Special Requests or Anticipated Problems (please specify)
