Form ADM 140, Language Access Complaint Instructions
This form contains 44 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Complainant Name | ||
| First Name | Text |
Enter the complainant’s first name.
|
| Last Name | Text |
Enter the complainant’s last name.
|
| Contact Information (Phone & Email) | ||
| Phone Area Code | Text |
Enter the three-digit area code of the telephone number where you can be reached.
|
| Phone Number | Text |
Enter the seven-digit telephone number (prefix and line number) where you can be reached.
|
| Email Address | Text |
Enter a valid email address where you can be reached.
|
| General | ||
| click to print | Button | |
| click to clear form | Button | |
| Incident Date | ||
| Incident Date | Date |
Enter the date on which the language access issue occurred (month, day, and year).
|
| Incident Location | ||
| Incident Location Street Address | Text |
Enter the street address of the DMV office or location where the incident occurred.
|
| Incident Location City | Text |
Enter the city of the DMV office or location where the incident occurred.
|
| Incident Location State | Text |
Enter the two-letter state abbreviation of the DMV office or location where the incident occurred.
|
| Incident Location ZIP Code | Text |
Enter the ZIP Code of the DMV office or location where the incident occurred.
|
| Language Assistance Needed | ||
| Armenian | CheckBox |
Check this box if you need assistance in Armenian.
|
| Cantonese | CheckBox |
Check this box if you need assistance in Cantonese.
|
| Hindi | CheckBox |
Check this box if you need assistance in Hindi.
|
| Korean | CheckBox |
Check this box if you need assistance in Korean.
|
| Mandarin | CheckBox |
Check this box if you need assistance in Mandarin.
|
| Punjabi | CheckBox |
Check this box if you need assistance in Punjabi.
|
| Spanish | CheckBox |
Check this box if you need assistance in Spanish.
|
| Tagalog | CheckBox |
Check this box if you need assistance in Tagalog.
|
| Vietnamese | CheckBox |
Check this box if you need assistance in Vietnamese.
|
| American Sign Language | CheckBox |
Check this box if you need assistance in American Sign Language.
|
| Other | CheckBox |
Check this box if you need assistance in a language not listed and specify the language in the provided space.
|
| Other Language (Specify) | Text |
Specify the language you need assistance with if it is not listed above. Fill only if the 'Other' is 'Yes'.
Depends on:
Other
|
| Mailing Address | ||
| Street Address | Text |
Enter your mailing street address, including house number, street name, and apartment or unit number if applicable.
|
| City | Text |
Enter the city associated with your mailing address.
|
| State | Text |
Enter the two-letter postal abbreviation for the state of your mailing address (e.g., CA for California).
|
| ZIP Code | Text |
Enter the five-digit ZIP Code for your mailing address.
|
| Method of Contact During Incident | ||
| In Person | CheckBox |
Check this box if the method of contact during the incident was in person.
|
| Telephone | CheckBox |
Check this box if the method of contact during the incident was by telephone.
|
| CheckBox |
Check this box if the method of contact during the incident was by email.
|
|
| Correspondence | CheckBox |
Check this box if the method of contact during the incident was through correspondence (e.g., mail or written communication).
|
| Other | CheckBox |
Check this box if the method of contact during the incident was not listed and specify the alternative method on the line provided.
|
| Other Contact Method | Text |
Specify the other method of contact you used during the incident. Fill only if the 'Other' checkbox is Yes.
Depends on:
Other
|
| Narrative Description of Incident | ||
| Narrative Description of Incident | Text |
Write a detailed description of the incident explaining how a language or communication barrier prevented you from accessing DMV services.
|
| Preferred Method of Contact | ||
| Telephone | CheckBox |
Check this box if you prefer to be contacted by telephone.
|
| CheckBox |
Check this box if you prefer to be contacted by mail.
|
|
| CheckBox |
Check this box if you prefer to be contacted by email.
|
|
| Type of Language Access Barrier | ||
| Lack of bilingual personnel | CheckBox |
Check this box if you were unable to access DMV services due to a lack of bilingual personnel.
|
| Lack of interpreter services | CheckBox |
Check this box if you were unable to access DMV services due to a lack of interpreter services.
|
| Lack of translated forms/materials | CheckBox |
Check this box if you were unable to access DMV services due to a lack of translated forms or materials.
|
| Lack of signs informing the public of interpreter/translation services | CheckBox |
Check this box if you did not see signs informing the public about available interpreter or translation services.
|
| Other | CheckBox |
Check this box if you experienced a different language access or communication barrier not listed above and will describe it in the space provided.
|
| Other barrier description | Text |
Describe any other language access or communication barrier not listed above. Fill only if the 'Other' checkbox is 'Yes'.
Depends on:
Other
|