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2. Date:
   Date:
4. First Name
   Name of person filing request
5. Last Name
7. Address Line 1
   Street address
9. Address Line 2
   e.g. apartment number, suite number
11. City
12. State
13. Zip
15. Phone Number
16. Email
18. Is this form being completed by an employee on behalf of the requester?

    1. Yes
    2. No
20. Name of Employee Taking Request
21. Work Phone Number
23. What is the nature of your accessibility needs?
    e.g. low vision, difficulty reading/understanding content, hearing loss, uses wheelchair
25. What material are you attempting to access?
    e.g. Board of Supervisors agenda for 3/20/2018
27. If applicable, what is the web address that contains the material you are trying to access?
29. What is the preferred format in which you wish to receive accessible material?
    e.g. Word document, described over phone
31. Other ways to request accessible information
    Users who need accessibility assistance can also contact us by phone through the Federal Information Relay Service at 1-800-877-8339 for TTY/Voice communication. If you would like to email a specific department, please find contact information in our staff directory.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field