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E-mail, Fax or
send a completed Optional Questionnaire to the
firm for review. If you choose to fax or send
the completed Questionnaire, please also attach
copies of the following
documents:
- Purchase
Agreement; Warranty Booklet which gives the
terms of the warranty;
- Any Extended
Warranty or Service Contract;
- All Repair
Orders;
- Any
Arbitration Documents;
- All
Correspondence you have sent to anyone
regarding your vehicle's defects or
problems;
- All Logs or
Notes you have kept regarding problems with
your vehicle, conversations with dealer
personnel about repairs, contacts with
manufacturer representatives,
etc.
Please organize
the documents in chronological order before
sending them. The information you submit will be
carefully evaluated and you will be notified if
it is believed that your case will be taken by
the firm. You will also be advised as to what
course of action is recommended in the event
that it is decided that the firm will not take
your case.
Name:
Mailing Address:
Home Phone:
()
Work
Phone:()
E-Mail Address:
Employer:
Address:
Vehicle Year/ Make/ Model:
Manufacturer:
Vehicle I.D. Number:
Selling Dealer:
Address:
Date Of Contract:
Vehicle Purchased Or
Leased:
Purchase or Lease
Price(Including
Financing or Capitalized Cost if a
Lease):$
Monthly Payment:
Number of Payments Made:
Lender:
Acct No.:
Address:
Was Financing Arranged
Through The Selling Dealer?:
Total Amount Paid:
$
Damages: (Downpayment
$)
(Out-Of-Pocket Repairs:
$)
(other:
)
Name And Address of
Dealers Who Have Repaired or Attempted To Repair
Your Vehicle:
Defects And Nonconformity
Problem(s):
Number Of Trips To The
Dealer For Repairs:
Total Number Of Days In
The Repair Shop:
Date Of The First Problem:
Mileage Of The First
Problem:
Total Number Of
Repair/Work Orders In Your Possession:
Did You Contact The
Manufacturer About Your Vehicle's Problems:
If Yes, Please
Indicate:
Person:
Title:
No. Of Contacts:
Letter Or Phone:
Do you Have Copies of
Letters:
Do You Have Notes Of
Telephone Calls:
Warranty Term:
months:
miles:
Extended Warranty/Service
Contract:
yes
no
If Yes, Terms Of Extended
Warranty/Service Contract:
months:
miles:
Was Case Arbitrated:
When:
What Were The
Results?:
Has Anyone Other Than A
Dealership Inspected Your Vehicle:
If Yes, When And By Whom?:
Whereabouts Of Vehicle:
Mileage
Did You Submit A Complaint
To Arbitration:
If Yes, When And How Did
It Resolve?:
Ongoing Problems With Your
Vehicle:
Accidents:
yes
no
If Yes, Please
Indicate:
number:
date(s):
Damage To Vehicle/Was
Damage Repaired?
How/Who Referred You To
This Law
Firm:
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