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ADA Reasonable Modification Form

Ver la versión en español de este formulario

View the ADA Reasonable Modification Request Policy

Please use this form to request a modification of the Mass Transit Department policy, program, service, or activity. Be specific and provide as much detail as possible. This will allow the Mass Transit Department to effectively process and evaluate your request.

With Respect to the Individual Expected to Benefit Directly from the Modification

Name

Street Address

City

State

Zipcode

Phone

Email Address

With Respect to Person Submitting Request, if different than above*

Submitter Name

Submitter Street Address

Submitter City

Submitter State

Submitter Zipcode

Submitter Phone

Submitter Email Address

Select the perferred method of contact

mail
phone
email

Please briefly describe the nature of your disability

Please describe what problem or issue you need addressed. What is the Mass Transit Department policy, program, service, or activity that is the subject of your modification request?

Describe the requested modification, and how this modification will help you access a Mass Transit Department policy, program, service, or activity.

Please be advised that, in order to evaluate this request, the Mass Transit Department may need to inquire as to the nature of your disability. If this information is provided to the Mass Transit Department, it will be maintained in a confidential manner.

* If you are submitting this request on behalf of someone else, you MUST submit proof of your legal relationship or legal authority to access that person’s confidential information.

Examples of legal relationship or legal authority include, but are not limited to:

Parent of a minor child
Guardian
Attorney-in-fact granted the power to act on the Individual’s behalf with respect to the Modification Request
Attorney of record
Individual authorized to act on behalf of the individual in a writing approved by the Department
Person with verifiable legal authority to act on behalf of the Individual with respect to the Modification Request

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e.g. 3685 Muldoon Rd Pensacola, FL 32526

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