STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATIONLANGUAGE ACCESS COMPLAINT FORM
DFPI-EEO 139 (Rev. 01-21)

Instructions for completing this form and routing it to the person handling this complaint is listed
below:The Department of Financial Protection and Innovation’s (DFPI) policy is to take reasonable steps toovercome language barriers to public services and programs. To do this, our goal is to:
1. Talk to you in your language, and
2. Make vital forms and documents accessible in your language.
Your comments on this form will help us towards that goal. All information is confidential. Please print,
and sign the form. Then send it by mail or email as shown below:
Department of Financial Protection and Innovation
Equal Employment Opportunity Office2101 Arena Blvd
Sacramento, CA 95834

FIRST NAME:

PART A: PERSON MAKING THE COMPLAINTLAST NAME:STREET ADDRESS:CITY:

TELEPHONE NUMBER:

E-MAIL ADDRESS:STATE:ZIP CODE:PREFERRED LANGUAGE:
IS SOMEONE ELSE HELPING YOU FILE
THIS COMPLAINT?
YESNOIF YES, PROVIDE THEIR NAME BELOW:FIRST NAME:LAST NAME:

PART B: NATURE OF THE PROBLEM
Check all boxes that apply and explain below:
I was not offered an interpreter.
I asked for an interpreter and was denied.
The interpreter(s) or translator(s) skills were not competent.
The interpreter(s) made rude or inappropriate comments.
The services took too long (Explain below).
I was not given forms or notices in a language I can understand (List documents needed below).
I was unable to use services, programs, or activities (Explain below).
Other (Explain below).

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATIONLANGUAGE ACCESS COMPLAINT FORM
DFPI-EEO 139 (Rev. 01-21) Page 2 of 3

When did the problem happen?

Date: (MM/DD/YYYY) __________________________
Time: ___________________

AM

PM

Where did the problem happen?
Describe what happened:

Did you complain to anyone from the Department/Agency? Who and what was the response?
Please be specific.

PART C: RESOLUTION
Date: (MM/DD/YY) ___________________________
Resolution:(I certify that this statement is true to the best of my knowledge and belief)
Signature: _____________________________ Date: (MM/DD/YYYY): _______________STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATIONLANGUAGE ACCESS COMPLAINT FORM

DFPI-EEO 139 (Rev. 01-21) Page 3 of 3

DFPI’s Privacy Notice on Collection
DFPI Collects and Uses Personal Information: The DFPI collects the information requested on
this form pursuant to the Dymally-Alatorre Bilingual Services Act authorizing DFPI to collectpersonal information. The DFPI uses this information for the purposes of providing better services
to the limited and non-English speaking public. Use of the personal Information DFPI collects is
subject to limitations contained in the Information Practices Act of 1977 and other applicable stateand federal laws.
Providing Personal Information Is Voluntary: If you do not want to provide personal
information, such as your name, home address or home telephone number, you may remain
anonymous. However, we may not be able to contact you or help resolve your issue.
When providing information or documents, please do not include unrequested personal
information such as a Social Security number, driver’s license number, or financial information.
DFPI May Disclose Your Personal Information: We may share your personal information with
the California Department of Human Resources (CalHR), the Department of Fair Employment andHousing, the Equal Employment Opportunity Commission, and other state and federal
government departments as required by law. Your personal information may also be disclosed:•••

In response to a Public Records Act request, as allowed by the Information Practices Act.
To another governmental agency as required by state or federal law.
In response to a court order or administrative order, a subpoena or a search warrant.

Your Access to Your Personal Information: You may review the records maintained by DFPI
that contain your personal information. To request access, contact: DFPI Privacy Officer, 2101
Arena Blvd, Sacramento, CA 95834, (866) 275-2677.