Fillable Aks nan Svis nan Lang Ou: Fm pou (New York Department of Motor Vehicles)

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Aks nan Svis nan Lang Ou: Fm pou (New York Department of Motor Vehicles)

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Aksè nan Sèvis nan Lang Ou: Fòm pou Fè Plent
Règleman Eta New York se pou fè etap rezonab pou metrize baryè lang pou sèvis ak pwogram piblik yo. Pou fè sa,
objektif nou se pou: 1) Pale avèk ou nan lang ou epi 2) Ba ou fòm ak dokiman enpòtan pami sis (6) premye yo, pi
souvan lang yo itilize, anplis lang Angle.
Kòmantè ou sou fòm sa a ap ede nou reyalize objektif sa a.
Tout enfòmasyon yo rete an sekrè.
Tanpri ekri an lèt detache, epi siyen fòm nan avèk lank nwa. Answit, voye li pa lapòs, nan faks, oswa nan imèl ki ekri
anwo a.
Moun k ap fè plent lan: # ID Moun ki Fè Plent lan (si li gen youn):
Prenon: Non fanmi:
Adrès ri:
Gran Vil, Ti Vil oswa Vilaj: Eta: Kòd postal:
Langaj ou pito: Imèl (sou genyen):
Nimewo Telefòn Kay: Lòt telefòn:
Èske yon lòt moun ede ou fè plent sa a? Wi Non Si se ‘Wi’, mete:
Prenon li:
Non fanmi li:
Kite pwoblèm ki te genyen? Koche tout kaz ki aplike yo, epi bay eksplikasyon anba la a.
Yo pa t ban mwen yon entèprèt
Mwen te m
ande yon entèprèt epi yo te refize ban mwen youn
Konpetans e
ntèprèt la (yo) oswa tradiktè a (yo) pa t bon (Bay non yo, si ou konnen y
o)
Entèprèt la (yo) te fè kòmantè gwosye oswa ki pa t apwopriye
Sèvis yo te pran twòp tan (Eksplike anba la a)
Yo pa t ban mwen fòm oswa avi nan yon lang mwen kapab konprann (bay dokiman ki nesesè yo anba la a)
Mwen pa t
kapab itilize sèvis, pwogram oswa aktivite yo (Eksplike anba la a)
Lòt (Eksplike anba la)
Kilè te gen pwoblèm nan? Dat (MWA/JOU/ANE): Lè: AM PM
Ki kote ki te gen pwoblèm nan?
Dekri sa ki t
e pase a. Tanpri pa ekri twòp bagay. Itilize paj siplemantè si li nesesè. Ekri non ou an lèt detache sou chak
fèy. Bay lang, sèvis ak dokiman ki nesesè yo. Mete non, adrès ak nimewo telefòn moun ki konsène yo, si ou konnen yo.
Èske ou te pote plent ba nenpòt moun nan Depatman/Ajans lan? Kimoun ak ki repons ou te jwenn? Tanpri pa ekri
twòp bagay.
Mwen konfime deklarasyon sa a vrè dapre tout sa mwen konnen ak kwè.
Siyati: _____________________________________________ Dat (MWA/JOU/ANE):
(Moun k ap fè plent lan)
Do not write in this box. For office use only / Pa ekri anyen nan kaz sa a. Pou biwo a itilize sèlman
Date:________________________ Reviewer:___________________________________________________________
Resolution:
LA 1HC (09/12)
New York State Department of Motor Vehicles
Language Access Review Board
6 Empire State Plaza - Room 432
Albany, NY 12228
(FAX) 518-473-3521
PA-7FC (10/12)
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Aks nan Svis nan Lang Ou: Fm pou (New York Department of Motor Vehicles)

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Completed 12 August 2021

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