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Automobile Dispute Settlement Program Request For Arbitration (Connecticut) - Legal Forms
| Automobile Dispute Settlement Program Request For Arbitration (Connecticut) Form. This is a Legal Forms form and can be used in Lemon Law Consumer . |
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STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION TRADE PRACTICES DIVISION, LEMON LAW UNIT AUTOMOBILE DISPUTE SETTLEMENT PROGRAM REQUEST FOR ARBITRATION INSTRUCTIONS 1. Read the entire Back In The Driver's Seat booklet before completing this application. We realize the application is lengthy, but we have found that all the information is essential to a timely and equitable resolution. Please call the Lemon Law office at (860) 713-6120 or 1-800-538-CARS if you have any questions regarding the application form. Type or print, using black ink, the answers to all questions. Be accurate and thorough, brief where indicated. Please do not respond to a question by writing "see attached" as documents are considered evidence supporting your response. If additional space is needed, use blank sheets of paper and reference the section being continued. Use 8-1/2" x 11" paper for additional information. Please do not write on the reverse side of any page and do not staple or tape pages together. A $50.00 filing fee must accompany this application. If your case does not qualify for arbitration the fee will be returned. Make checks payable to the "Treasurer State of Connecticut". DO NOT SEND CASH. The purchaser(s) of the vehicle specified in this application must sign the Agreement to Arbitrate on Page 11 in the presence of a notary public or Commissioner of Superior Court. If a corporation owns the vehicle, an officer of the company must sign the Agreement to Arbitrate and represent the company in the arbitration proceedings. If required in the warranty or owner's manual, you must send written notification to the manufacturer at the address indicated in the warranty or owner's manual of your intent to file a complaint under lemon law. Please provide a copy of the letter sent to the manufacturer with your application, and annotate page 7 question 7 accordingly. Submit the Request for Arbitration, required documents, and filing fee to: Department of Consumer Protection Automobile Dispute Settlement Program 165 Capitol Avenue Hartford, Connecticut 06106 2. 3. 4. 5. 6. American LegalNet, Inc. www.FormsWorkFlow.com Request for Arbitration Owner (s) Information For office use only: Case number: Received: Completed: Page 1 Name of purchaser (s): Street address: City: State: Zip code: Telephone: (indicate name if more than one purchaser) Home: ( ) Work: ( ) Vehicle information: Year: Make / Manufacturer: Model: Mileage at the time of purchase: Current mileage: Do you have an automatic or standard transmission: Vehicle identification number: Purchase date: Delivery date: Did you receive a manufacturer's rebate? If yes, what amount: Selling dealer: Address: City: State: Zip code: Are you the original purchaser? If no, name and address of the original purchaser (s) if known Complete only if the vehicle is leased. The Lemon Law allows the leasing company to participate in the arbitration procedure. You must notify the company by a certified or registered letter of your intent to file for an arbitration hearing before you submit the Request for Arbitration form to the Automobile Dispute Settlement Program. Include a copy of the postal receipt confirming the use of certified or registered mail. The leasing company address where you need to write to appears on the vehicle registration under "Registrants" Name of leasing dealer: Address: City: State: Zip code: Name of leasing company: Address: City: State: Zip code: If you intend to be represented by an attorney, or a third party complete the following. All Correspondence will be directed to the party representing you. Attorney's Name Street Address City State Zip Code Telephone Number ( ) Third Party's Name Street Address City Telephone Number ( State ) Zip Code On the following pages provide information regarding all repair attempts. List each repair attempt on a separate page. Begin with the first occurrence. Be sure to include all pertinent information such as problems you experienced with your vehicle, any towing charges, work performed, what the servicing dealer told you, etc. If known, give name and title of the person with whom you spoke. If you wrote to the dealer or the manufacturer, provide a copy of the correspondence. Keep in mind our cases are public; please remove any and all personal information. American LegalNet, Inc. www.FormsWorkFlow.com Request for Arbitration FIRST REPAIR: FROM (Date): Repair Order Number: Servicing Dealer: Street Address: City: State: Zip Code: Was the repair covered by the terms of the manufacturer's new car warranty? Amount you paid for this repair including a deductible, if any: Describe the nature of the problem(s): TO (Date): Mileage: Page 2 Number of days the vehicle was in the shop for this service: Indicate the repair(s) performed including the name and title, if known, of any person performing the repairs. Indicate the business address of the person performing the repairs if different from the servicing dealership. American LegalNet, Inc. www.FormsWorkFlow.com Request for Arbitration SECOND REPAIR: FROM (Date): Repair Order Number: Servicing Dealer: Street Address: City: State: Zip Code: Was the repair covered by the terms of the manufacturer's new car warranty? Amount you paid for this repair including a deductible, if any: Describe the nature of the problem(s): TO (Date): Mileage: Page 3 Number of days the vehicle was in the shop for this service: Indicate the repair(s) performed including the name and title, if known, of any person performing the repairs. Indicate the business address of the person performing the repairs if different from the servicing dealership. American LegalNet, Inc. www.FormsWorkFlow.com Request for Arbitration THIRD REPAIR: FROM (Date): Repair Order Number: Servicing Dealer: Street Address: City: State: Zip Code: Was the repair covered by the terms of the manufacturer's new car warranty? Amount you paid for this repair including a deductible, if any: Describe the nature of the problem(s): TO (Date): Mileage: Page 4 Number of days the vehicle was in the shop for this service: Indicate the repair(s) performed including the name and title, if known, of any person performing the repairs. Indicate the business address of the person performing the repairs if different from the servicing dealership. American LegalNet, Inc. www.FormsWorkFlow.com Request for Arbitration FOURTH REPAIR: FROM (Date): Repair Order Number: Servicing Dealer: Street Address: City: State: Zip Code: Was the
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