AMERICANS WITH DISABILITES ACT ACCOMMODATION (ADA) TITLE II  REQUEST FOR REASONABLE ACCOMMODATION FORM 
(INCLUDES REQUEST FOR INTERPRETER FOR HEARING /SPEECH IMPAIRED) 

Requestor Information – Section A 

Name: 

Address: 

Please check the box that most closely describes your status in this matter: 

 Attorney        

 Program Participant   

 Other (please explain) 

Requestor Information   (if different from above) 

Accommodation 
Nature of the disability for which an accommodation is requested: 

Name: 

Address: 

Relationship 
to Client: 

Accommodation requested: 

Name of Office: 

Address: 

Phone: 

Email: 

Mobile: 

Bus. Phone/ 
Mobile: 

Fax: 

Email: 

TTY: 

Location of AOPC Program/Activity 

AOPC Program/Activity Information (if known) 

AOPC Program/ Activity: 

AOPC Contact: 

Date of Event: 

Time of Event: 

Program/Activity Type: 

AFTER  COMPLETING  THE  FORM,  PLEASE  SEND  TO:    Marisa  Lehr,  ADA  Coordinator,  AOPC,  P.O.  Box  61260,  Harrisburg,  PA  17106-1260 
 marisa.lehr@pacourts.us, 717-231-3300  

I hereby certify that an Americans with Disabilities Act accommodation is required in the above-captioned action on the date stated. 

Signature: 

           

Date: 

FOR OFFICIAL USE ONLY 
Service Provider Information - Section B 
A SERVICE REQUEST HAS BEEN MADE FOR THE CLIENT NAMED ABOVE.   

Service Provider Company:  

Individual Interpreter Name: 

Bus. Phone/ Mobile: 

Court Official Verification – Section C 

Start Date & Time: 

AOPC Official: 

(Please print name) 

Title: 

Fax: 

Email: 

Date to Provider: 

End Date & Time: 

Signature: 

Date: 

VERIFYING OFFICIAL SHALL MAINTAIN A COPY IN AOPC’S PROGRAM FILES AND PROVIDE THE ORIGINAL TO THE SERVICE PROVIDER FOR SUBMISSION WITH BILLING. 

I hereby verify that the services were performed by the provider in the above-captioned action on the date and time stated.