Please return this completed form to the Lehigh County Court ADA Coordinator, Colleen Weber, 455 W. Hamilton Street, Allentown, PA 18101. (610)782-3223, (610) 782-782-3866 Fax, E-mail: ADAcoordinator@lehighcounty.org as far in advance as possible, but at a minimum of (5) five days before your scheduled court appearance or other court activity.

1.	Date:
2.	Person needing accommodation
Name:
Are you (please check one)
Defendant	Plaintiff	Witness	Juror	Victim
Attorney	Other: (please specify)
3.	Contact Information for person needing accommodation
STREET ADDRESS OR P.O BOX
CITY
STATE
ZIP CODE
TELEPHONE ( include area code)
EMAIL ADDRESS
4.	Person making request (if other than the person needing the accommodation)
Name:
TELEPHONE ( include area code)
EMAIL ADDRESS
Relationship to person needing an accommodation:
5.	Case Information (if applicable)
Case number, if known:
Case caption, if known:
Judge, if known:
Date(s) accommodation needed:
Time accommodation needed:
Location (courthouse/courtroom) accommodation needed:
Duration for which accommodation is requested:
Type of case, if known
Civil	Criminal	Family Court	Juvenile	Orphans’ Court
Appeal	Other: (please specify)

6.	Nature of Disability
Nature of disability for which an accommodation is requested:
7.	Accommodation requested (please check on of the following)
Sign Language Interpreter (Please specify American Sign Language, oral interpreter, signed English, or other type of signing system used by persons with hearing loss.):
Assignment of courtroom that is accessible to a person using mobility device (Please specify wheelchair, scooter, walker, or other mobility device that is used.):
Other accommodation (Please specify)

LEHIGH COUNTY COURT SYSTEM TITLE II ADA REASONABLE ACCOMMODATION REQUEST FORM

Rachel A Wotring

2017-04-25