Review of Accommodation Request

Reference Number*
Full Name*
Home Phone*
Work Phone
Email Address
Street Address*
City, State, Zip*
Reason Requested*
Tarrant County Disclosure Statement *
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Please fill out the following form and press submit. Information contained within this form is considered confidential, and will only be provided to the parties involved in the evaluation process.

Reference Number*

Full Name*

Home Phone*

Work Phone

Email Address

Street Address*

City, State, Zip*

Please describe why you disagree with the response of the ADA Officer to your request for accommodation. Please provide any specific information that you may have relating to sources, names of devices, etc.

Reason Requested*

Tarrant County Disclosure Statement *

Please be aware that some or all of the information that you submit using this form is subject to public disclosure under the Texas Public Information Act. For an overview of this act, visit the Texas Attorney General's website.

I have read and understand the information above.

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