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Grievance Request

Americans with Disabilities Act (ADA) Accommodation Request Forms
NOTE: If your requestis for the Superior Court and not the Clerk of the Court, see http://www.superiorcourt.maricopa.gov/SuperiorCourt/AmericansWithDisabilitiesAct/Index.asp
Complainant Information *  Required Field
First Name *
Last Name *
Street Address *
Address 2  
City: *    State: *    Zip: * 
Phone: *    TDD (check if Telecommunications Device for the Deaf)
Email Address:
Please complete the following: *  Required Field
1. Nature of Disability*  
2. Location: *  
3. Date and time of alleged discrimination: *
Date:    (Date Format:  mm/dd/yyyy)          Time:    
4. Please describe the way in which you believe you were denied the benefit, service, program, or activity of the Clerk, or have otherwise been subject to discrimination as a person with a disability by the Clerk: *
5. Please state, if known, the names or positions of any Clerk of the Superior Court employees involved in the incident, as well as names, addresses and telephone numbers of any witnesses to such incident, if necessary: *

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