Request for Dispute Assistance

Not Yet Approved by OMB
3060-0874
Estimated time per response: 30 minutes

Request for Dispute Assistance
(explanations and filing instructions)
Please use this form to request assistance from the FCC Disability Rights Office to resolve an
accessibility or usability problem related to telecommunications or advanced communications services
or equipment. The FCC Disability Rights Office must work with you and the company for at least 30
days to try to resolve your accessibility problem before you can file an informal complaint with the FCC.
You may request additional time for this assistance. After 30 days, if your problem is not resolved, you
may file an informal complaint with the FCC Enforcement Bureau.
Complete the sections as indicated below. Sections marked with an asterisk (*) must be completed. If
you need assistance completing or submitting this form, or if you have any questions, please contact
the FCC Disability Rights Office at [email protected] or call 202-418-2517 (voice) or 202-418-2922 (TTY).
* Select the type of service or equipment that best describes your accessibility problem:
wireless or mobile telephone service or equipment (such as a cellphone or smartphone)
wireline or landline telephone service or equipment (such as your home phone)
cable or Internet phone service or equipment (such as home phone service provided by your
Internet service provider)
Internet voice communication service or equipment (such as using your computer to talk to a
friend)
electronic messaging service or equipment (such as text messaging, instant messaging, or e-mail)
interoperable video conferencing service or equipment
Accessibility specifically required for individuals who are blind or visually impaired:
Internet browser built into a wireless or mobile telephone (such as a cellphone or smartphone)
Your Contact Information:
* First Name:

* Last Name:

* Street Address or Post Office Box Number:
* City:

* State:

* Zip Code:

Please provide both a phone number and an e-mail address, if available.
Telephone Number:
Area Code (

)

-

Ext:

Voice
Videophone
TTY
E-mail Address:

We plan to contact you by e-mail and/or phone. If these methods of communication are not
accessible to you, please indicate your preferred format or method of response:

Are you filing this request on behalf of a company or organization?

Yes

No

When “Yes” is selected, the following information is requested:
Name of company or organization:
Your job title:

Are you filing this request on behalf of another person, such as a family member or friend?
Yes

No

When “Yes” is selected, the following information is requested:
Name of the other person:
First name:
Last name:
Your relationship to this person:

Information about Your Accessibility Problem:
1. Provide the following information about your equipment and service. Check all that apply.
Equipment Manufacturer
Name:
The type of device (such as cellphone, smartphone, or computer):

Model number:
Service Provider
Name:
Software/App
Name of software/app:
Version:
Name of Internet browser:
Version:
2. Please provide the approximate date the service or equipment was purchased, acquired, or used
(or attempted to be purchased, acquired, or used):
Month:

Year:

Date when you became aware of the accessibility problem:
Month:

Year:

3. * Briefly describe the way the service or equipment is not accessible or
usable. Be as specific as possible. If desired, you may submit additional
information or documents. Follow the instructions below.

Character Count:

(1,000 characters maximum)

4. Did you contact anyone in the company about this accessibility problem
before filing this Request for Dispute Assistance? If yes, please provide the date,
name of the person or department you contacted, and the phone number, if
available. Please describe what happened when you contacted the company.

Character Count:

(1,000 characters maximum)

5. * What would you like the company to do to solve your accessibility problem?

Character Count:

(1,000 characters maximum)

6. Please provide any other information you think may be useful to solve your
accessibility problem.

Character Count:

(1,000 characters maximum)

ADDITIONAL INFORMATION: Please select how you want to submit additional information, if any,
related to this Request for Dispute Assistance:

Select

The following instructions appear when “Electronically” is selected:
You may attach a copy of an electronic version of a file saved on your computer. Most file types,
including image files, text documents, and PDFs are accepted. Files may not be larger than 10 MB.
File to upload: [text box where file name will appear]
[Browse]
[Attach File]
To attach a file, select "Browse." A window will appear which will allow you to navigate to your file's
location. Double-click on the file, or highlight it and select "Open." When the file path appears in
the “File to upload” box, select "Attach." When attached, a confirmation message will be displayed
along with the file name.

The following instructions appear when “Fax” is selected:
Upon submission of this Request for Dispute Assistance, a confirmation page will be displayed. 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 and use this confirmation page or confirmation e-mail as a cover sheet
and fax your documents to 1-866-418-0232 (toll-free).

The following instructions appear when “Postal Mail” is selected:
Upon submission of this Request for Dispute Assistance, a confirmation page will be displayed. 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 and use this confirmation page or confirmation e-mail as a cover sheet
for mailing copies of documents. Please keep a copy of the confirmation page for your records. Mail
your documents to:
Federal Communications Commission
Consumer & Governmental Affairs Bureau
Consumer Requests for Dispute Assistance
445 12th Street, SW
Washington, D.C. 20554

Upon submission of this Request for Dispute Assistance, a confirmation page will be displayed with
your case number and information about how your request 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.
By clicking on the "Submit" button below, your Request for Dispute Assistance will be directed to the
FCC Disability Rights Office.
Submit