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ADA Reasonable Modification Form

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

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

Select the perferred method of contact

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:

  1. Parent of a minor child
  2. Guardian
  3. Attorney-in-fact granted the power to act on the Individual’s behalf with respect to the Modification Request
  4. Attorney of record
  5. Individual authorized to act on behalf of the individual in a writing approved by the Department
  6. Person with verifiable legal authority to act on behalf of the Individual with respect to the Modification Request
e.g. 3685 Muldoon Rd Pensacola, FL 32526
e.g. Cordova Mall
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