{"id":565,"date":"2020-10-02T14:03:41","date_gmt":"2020-10-02T18:03:41","guid":{"rendered":"https:\/\/mydaycounts.org\/?page_id=565"},"modified":"2021-07-21T09:19:52","modified_gmt":"2021-07-21T13:19:52","slug":"file-a-transportation-complaint","status":"publish","type":"page","link":"https:\/\/mydaycounts.org\/who-we-are\/file-a-transportation-complaint\/","title":{"rendered":"File A Transportation Complaint"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:80px;--awb-padding-bottom:60px;--awb-margin-top:0px;--awb-margin-bottom:0px;--awb-background-color:#f2f2f2;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-567\"><form id=\"wpforms-form-567\" class=\"wpforms-validate wpforms-form\" data-formid=\"567\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/565?wpforms_form_id=567\" data-token=\"1fcd63ed7a610b79f0def90e43e11625\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-567-field_8-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"8\"><h3 id=\"wpforms-567-field_8\" name=\"wpforms[fields][8]\">Section I<\/h3><\/div><div id=\"wpforms-567-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_0\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-567-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-567-field_0\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-567-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-567-field_0-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-567-field_3-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_3\">Phone<\/label><input type=\"tel\" id=\"wpforms-567-field_3\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][3]\" ><\/div><div id=\"wpforms-567-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-567-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-567-field_5-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_5\">Accessible Format Requirements?<\/label><ul id=\"wpforms-567-field_5\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_5_1\" name=\"wpforms[fields][5][]\" value=\"Large Print\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_5_1\">Large Print<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_5_2\" name=\"wpforms[fields][5][]\" value=\"Audio Tape\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_5_2\">Audio Tape<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_5_3\" name=\"wpforms[fields][5][]\" value=\"TDD\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_5_3\">TDD<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_5_4\" name=\"wpforms[fields][5][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_5_4\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-567-field_9-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"9\"><h3 id=\"wpforms-567-field_9\" name=\"wpforms[fields][9]\">Section II<\/h3><\/div><div id=\"wpforms-567-field_13-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_13\">Are your filing this complaint on your own behalf? (copy)<\/label><ul id=\"wpforms-567-field_13\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_13_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][13][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_13_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_13_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][13][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_13_2\">No<\/label><\/li><\/ul><div class=\"wpforms-field-description\">If Yes, go to Section III<\/div><\/div><div id=\"wpforms-567-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_10\">If no, what is the name of the person for whom you are filing this complaint?<\/label><input type=\"text\" id=\"wpforms-567-field_10\" class=\"wpforms-field-large\" name=\"wpforms[fields][10]\" ><\/div><div id=\"wpforms-567-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_11\">What is your relationship with this individual?<\/label><input type=\"text\" id=\"wpforms-567-field_11\" class=\"wpforms-field-large\" name=\"wpforms[fields][11]\" ><\/div><div id=\"wpforms-567-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_12\">Please explain why you have filed for a third party.<\/label><input type=\"text\" id=\"wpforms-567-field_12\" class=\"wpforms-field-large\" name=\"wpforms[fields][12]\" ><\/div><div id=\"wpforms-567-field_7-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_7\">Please confirm that you have obtained permission of the aggrieved party to file on their behalf.<\/label><ul id=\"wpforms-567-field_7\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_7_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][7][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_7_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_7_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][7][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_7_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-567-field_14-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"14\"><h3 id=\"wpforms-567-field_14\" name=\"wpforms[fields][14]\">Section III<\/h3><\/div><div id=\"wpforms-567-field_15-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_15\"> I believe the discrimination I experienced was based on (Check all that apply):<\/label><ul id=\"wpforms-567-field_15\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Race\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_15_1\">Race<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_15_2\" name=\"wpforms[fields][15][]\" value=\"Color\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_15_2\">Color<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_15_3\" name=\"wpforms[fields][15][]\" value=\"National Origin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_15_3\">National Origin<\/label><\/li><\/ul><\/div><div id=\"wpforms-567-field_16-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_16\">Date of alleged discrimination<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-567-field_16\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][16][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-567-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_2\">Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known), as well as names and contact information of any witnesses. <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-567-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/textarea><\/div><div id=\"wpforms-567-field_17-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"17\"><h3 id=\"wpforms-567-field_17\" name=\"wpforms[fields][17]\">Section IV<\/h3><\/div><div id=\"wpforms-567-field_18-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_18\">Have you previously filed a Title VI complaint with Orange Country Adult Achievement Center?<\/label><ul id=\"wpforms-567-field_18\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_18_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][18][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_18_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][18][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_18_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-567-field_28-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"28\"><h3 id=\"wpforms-567-field_28\" name=\"wpforms[fields][28]\">Section V<\/h3><\/div><div id=\"wpforms-567-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_27\">Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? (copy)<\/label><ul id=\"wpforms-567-field_27\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_27_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_27_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_27_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_27_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-567-field_19-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_19\">If yes, check all that apply:<\/label><ul id=\"wpforms-567-field_19\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_19_1\" name=\"wpforms[fields][19][]\" value=\"Federal Agency\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_19_1\">Federal Agency<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_19_2\" name=\"wpforms[fields][19][]\" value=\"Federal Court\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_19_2\">Federal Court<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_19_3\" name=\"wpforms[fields][19][]\" value=\"State Agency\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_19_3\">State Agency<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-567-field_19_5\" name=\"wpforms[fields][19][]\" value=\"Local Agency\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-567-field_19_5\">Local Agency<\/label><\/li><\/ul><\/div><div id=\"wpforms-567-field_21-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"21\"><h3 id=\"wpforms-567-field_21\" name=\"wpforms[fields][21]\">If yes, provide information about a contact person at the agency\/court where the complaint was filed.<\/h3><\/div><div id=\"wpforms-567-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_20\">Name<\/label><input type=\"text\" id=\"wpforms-567-field_20\" class=\"wpforms-field-large\" name=\"wpforms[fields][20]\" ><\/div><div id=\"wpforms-567-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_22\">Title<\/label><input type=\"text\" id=\"wpforms-567-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-567-field_26-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_26\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-567-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-567-field_25-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_25\">Phone<\/label><input type=\"tel\" id=\"wpforms-567-field_25\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][25]\" ><\/div><div id=\"wpforms-567-field_32-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_32\">Phone<\/label><input type=\"tel\" id=\"wpforms-567-field_32\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][32]\" ><\/div><div id=\"wpforms-567-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_24\">Address<\/label><input type=\"text\" id=\"wpforms-567-field_24\" class=\"wpforms-field-large\" name=\"wpforms[fields][24]\" ><\/div><div id=\"wpforms-567-field_29-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"29\"><h3 id=\"wpforms-567-field_29\" name=\"wpforms[fields][29]\">Section VI<\/h3><\/div><div id=\"wpforms-567-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_30\">Name of Transit Agency complaint is against<\/label><input type=\"text\" id=\"wpforms-567-field_30\" class=\"wpforms-field-large\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-567-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_31\">Contact Person<\/label><input type=\"text\" id=\"wpforms-567-field_31\" class=\"wpforms-field-large\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-567-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_23\">Agency<\/label><input type=\"text\" id=\"wpforms-567-field_23\" class=\"wpforms-field-large\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-567-field_33-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_33\">You may attach any additional materials or other information that you think is relevant to your complaint.<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"33\"\n\t\tdata-form-id=\"567\"\n\t\tdata-input-name=\"wpforms_567_33\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,ico,heic,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,json\"\n\t\tdata-max-size=\"10485760\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"10485760\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to upload.<\/span>\n\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-567-field_33\"\n\t\tname=\"wpforms_567_33\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-567-field_34-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-567-field_34\">Signature and date are required below to complete form:<\/label><input type=\"text\" id=\"wpforms-567-field_34\" class=\"wpforms-signature-input wpforms-screen-reader-element\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][34]\" autocomplete=\"off\" ><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-567-field_34-signature\" 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