UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF INDIANA Request for Accommodation for Person with Communication Disability In Re: * Case Number * In accordance with the policy of the Judicial Conference of the United States, and the policy and guidelines of this Court, the undersigned requests a Court provided language interpreter and/or other appropriate auxiliary aids and services as follows: (Check one) Sign language interpreter Sign language interpreter Other communication aid, auxiliary aid or service (specify): Other communication aid, auxiliary aid or service (specify): Who is the Judge hearing your matter? * What is the Hearing Date/Time/Location? * What is your role in the hearing? (Check one) Debtor Defendant Plaintiff Witness Other (specify): Other Option I certify under penalty of perjury that I am deaf, hearing impaired, or have other communication disabilities that render me eligible for receipt of these services. Applicant's Name (printed): * Phone: * Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Email: * This Request for Accommodation must be submitted to the Court at least fourteen (14) days before the date of the hearing. Submission can be made by hitting the “Submit Now” button below. Questions can be emailed to the Court's Access Coordinator.
