New Car Lemon Law Dispute Resolution Application Page 3
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What was the mileage on delivery? ______________________
Present mileage: _____________________
5.
Date of delivery: ____________________________________
Month
Day
Year
6. The vehicle identification number (the VIN can be found on the registration): _________________________________________
7. Dealer from which the vehicle was purchased or leased:
Name: ____________________________________________________ Telephone number : _____________________________
(include area code)
Street Address: ___________________________________________________________________________________________
City: ______________________________________ State: ______________________________ ZIP code: _______________
8. Company to which you make monthly payments:
Name: ____________________________________________________ Telephone number : _____________________________
(include area code)
Street Address: ___________________________________________________________________________________________
City: ______________________________________ State: _______________________________ ZIP code: _______________
Please provide the loan or lease account number: ________________________________________________________________
Financial Information
9. Please attach a copy of all sales or lease documents and receipts.
10. Other costs, including: any towing charges, rental fees and/or cost of modifications.
Please specify and attach receipts _________________________________________________________ .
Nonconformity Repair Information
11. Briefly describe the defect which substantially impairs your vehicle’s use, value or safety.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
12. Is this defect the result of your abuse, neglect or an unauthorized modification or alteration?
Yes
No
If “Yes,” please explain: ___________________________________________________________________________________
_______________________________________________________________________________________________________
13. Have you notified the manufacturer of the defect, by certified mail , return receipt requested?
Yes
No
What was the certified mail return receipt date? _______________ What was the vehicle’s mileage at the time? _____________
14. Was there a final repair attempt?
Yes
No
If “Yes,” what was the date of the final repair attempt? _____________________________________
What was the vehicle’s mileage at the time of the final repair attempt? __________________________
If “No,” please explain: ____________________________________________________________________________________
_______________________________________________________________________________________________________
15 . Was the vehicle ever repaired by anyone other than a dealer authorized by the manufacturer?
Yes
No
If “Yes,” by whom? _______________________________________________________________________________________
16. If you answered “Yes” to question number 15, was that repair authorized by the manufacturer or its dealer?
Yes
No
17. What was the date you first presented your vehicle to the dealer for repair of the defect? _________________________________
What was the vehicle’s mileage at the time? _________________________________
18. If your vehicle experienced one or more defects, was the car out of service due to repairs for a total of 20 or more days?
If “Yes,” how many days? __________________
Yes
N o
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