2000H Communications Accessibility Informal Complaint

Not Yet Approved by OMB
3060-0874
Estimated time per response: 15 minutes

FORM 2000H - Communications Accessibility Informal Complaint
The information on this informal complaint, including your contact information, the names and addresses of the company or
companies, and the summary of your informal complaint was derived from information that you provided on your Request for
Dispute Assistance and from information provided to the FCC Disability Rights Office. If your contact information has changed,
you will be able to provide new contact information below. However, the names and addresses of the companies and the
summary of your informal complaint cannot be changed to ensure that the informal complaint addresses the accessibility
problem that was the subject of your Request for Dispute Assistance. If you disagree with the summary of your informal
complaint presented below, e-mail the FCC Disability Rights Office at dro@fcc.gov or call 202-418-2517 (voice) or 202-418-2922
(TTY) for assistance.
FILING PARTY INFORMATION:
[First Name / Last Name]
[Street Address or Post Office Box Number]
[City, State Zip Code]
[E-mail Address]
[Telephone Number] [Ext.] [voice / videophone / TTY]
* Is your contact information still correct?

Yes

No

When “No” is selected, the following information is requested:
Enter your new contact information below.
First Name:
Last Name:
Street Address or Post Office Box Number:

City:
Telephone Number: Area code (
E-mail Address:

State:
)

-

Ext:

Zip Code:

FILED ON BEHALF OF A COMPANY, ORGANIZATION, OR ANOTHER PERSON:
Name of company or organization:
Your job title:

[Name of company or organization]
[Your job title]

First name of other person:
Last name:
Your relationship to the other person:

[First name]
[Last name]
[Relationship]

RESPONDING ENTITIES:
Equipment Manufacturer:
[Equipment Manufacturer
Name]
Type of Device:
[Type of Device]
Model Number:
[Model Number]

Service of Process Contact Information
(The FCC Enforcement Bureau will send this informal complaint to this
company.)
[First Name / Middle Initial / Last Name / Suffix]
[Title]
[Company Name]
[Address Line 1]
[Address Line 2]
[City, State Zip Code]
[Phone number] Ext: [Extension number]
[Fax number]
[E-mail address]

Service Provider:
[Service Provider Name]

Service of Process Contact Information
(The FCC Enforcement Bureau will send this informal complaint to this
company.)
[First Name / Middle Initial / Last Name / Suffix]
[Title]
[Company Name]
[Address Line 1]
[Address Line 2]
[City, State Zip Code]
[Phone number] Ext: [Extension number]
[Fax number]
[E-mail address]

Software/App Name: [Name]
Internet Browser: [Name]

Version: [Version]
Version: [Version]

SUMMARY OF INFORMAL COMPLAINT:
Complaint Type:
[Complaint Type]
Date purchased/acquired/used or attempted to purchase/acquire/use the equipment or service:
Date1: [Date1]
Date became aware of accessibility problem:
Date2: [Date2]
The information below describes the way the equipment or service is not accessible or useable and may violate Section 255,
716, or 718 of the Communications Act or the FCC’s rules.
[description of the way the service or equipment is not accessible or usable]
The information below describes whether you contacted the company about the accessibility problem, information about
who you contacted, and what happened when you contacted the company.
[description of any contact with the company before filing the RDA]
What would you like the company to do to solve your accessibility problem?
[description of desired resolution]
Other information you think may be useful to solve your accessibility problem:
[other information that may be useful]
The following is information that you previously provided to the FCC Disability Rights Office in connection with your Request for
Dispute Assistance and is included as part of your informal complaint:
[system to list files names of electronically filed or scanned documents included as part of this complaint]
* Is this complaint related to another complaint or complaints?

Yes

No

When “Yes” is selected, the following information is requested:
If yes, enter the complaint file number(s) below and explain how the complaints are related:

* Please select one of the following methods to receive a response from the manufacturer/service provider:
E-mail
Letter
If these methods of communication are not accessible to you, please indicate your preferred format or method of response:

If you choose to file this informal complaint as summarized above, your complaint will be directed to the FCC Enforcement
Bureau for processing.
Upon submission of this informal complaint, a confirmation page will be displayed with your complaint number and information
about how your complaint will be processed. If you provided an e-mail address above, the information on the confirmation
page will also be sent to you by e-mail. Please print the confirmation page and/or save the confirmation e-mail for future
reference.
If you choose not to file this informal complaint as summarized above, your complaint will not be filed.
If you need help or have questions about the information in your informal complaint above, or about information that should
be included in your informal complaint, e-mail the FCC Disability Rights Office at dro@fcc.gov or call 202-418-2517 (voice) or
202-418-2922 (TTY) before submitting this informal complaint.
By submitting this informal complaint, I, the above-named filing party, certify, under penalty of perjury, that I submitted a
Request for Dispute Assistance at least 30 days ago and that the information provided in this informal complaint is correct to
the best of my knowledge.

Submit