Disability Accommodation Request Form

Disability Accommodation Request Form District Court of Singaraja class IB
FREE OF CHARGE

If you have a disability and need an accommodation while you are at court, you can use this form to make your request.
Case Number
Case Type
1. Personal Information
Name*
Address*
Phone number*
Email*
contoh@contoh.com
PetitionerPlaintiffVictimDefendantLawyerWitnessExpertOther
3. When and where do you need the accommodation? Date(s) and time(s)*

HariBulanTahun
Tanggal
Disability equipment(s)Medical roomDrug/medicineAide/caregiverTranslatorPick-up service to the CourtOther
5. Why do you need this accommodation to assist you in court?*
Date*

HariBulanTahun
Tanggal
Full name*
Signature*

Bersihkan
If a court employee, caregiver or other person helped fill out this form and is willing to provide more information needed, provide information bellow:
Name
Phone
Status
Disability Accommodation Request Form District Court of Singaraja Class IB
Should be Empty:

FREE OF CHARGE