Florida State Courts System
ADA Title ll Accommodation Request Form
Sixth Judicial Circuit

Please submit this completed form as far in advance as possible, but preferably at least seven (7) days before your scheduled court appearance or other court activity.

1.	Date request submitted: / /20
2.	Person needing accommodation
	Name:
	Are you (please check one of the following seven options):
	Defendant Litigant/Party Witness Juror Victim Attorney Other (please specify):
3.	Contact information for person needing accommodation
	Street or P.O. Box:
	City:
	State: Zip Code:
	Telephone Number (include area code):
	Email Address:
4.	Person making request (if other than the person needing the accommodation)
	Name:
	Telephone Number (include area code):
	Email Address:
	Relationship to person needing an accommodation:
5.	Case information (if applicable)
	Style of case (case title), if known:
	Case number:
	Judge, if known:
	Date accommodation needed:
	Time accommodation needed:
	Location (courthouse/courtroom) accommodation needed:
	Duration for which the accommodation is requested:
	Type of case, if known (please check one of the following ten options):
	appeal circuit criminal circuit civil family court
	probate, guardianship, or mental health county criminal county civil
	traffic court small claim other (please specify)
	Type of proceeding, if known (please check one of the following six options):
	arraignment bond hearing hearing trial appellate oral argument
	other (please specify)
6.	Accommodations requested
	Nature of disability that necessitates accommodation:
	Accommodation requested (please check one of the following six options):
	Assistive listening device (Assistive listening systems work by increasing the loudness of sounds, minimizing background noise, reducing the effect of distance, and overriding poor acoustics. The listener uses a receiver with headphones or a neckloop to hear the speaker.)
	Communication access real-time translation/real-time transcription services (CART is a word-for-word speech-to-text interpreting service for people who need communication access. A rendering of everything said in the courtroom will appear on a computer screen. CART is not an official transcript of a court proceeding.)
	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 to a courtroom that is accessible to a person using a mobility device (Please specify wheelchair, scooter, walker, or other mobility device that is used.):
	Provision of court documents in an alternative format (Please specify Braille, large print, accessible electronic document, or other accessible format used by persons who are blind or have low vision.):
	Other accommodation (please specify):

*your e-mail address is required to submit form

E-mail addresses are public records under Florida law and are not exempt from public-records requirements. If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity. Instead, contact this office by telephone (main number is 727-464-4880) or in writing, via the United States Postal Service at

Pinellas County ADA Coordinator
400 S. Fort Harrison Ave.
5th Floor
Clearwater, Florida 33756

An alternate PDF version of this form is available here

Florida State Courts System ADA Title ll Accommodation Request Form Sixth Judicial Circuit

Florida State Courts System
ADA Title ll Accommodation Request Form
Sixth Judicial Circuit