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Customer Claim Form To BBB Auto Line (California) - Legal Forms
| Customer Claim Form To BBB Auto Line (California) Form. This is a Legal Forms form and can be used in Lemon Law Consumer . |
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Customer Claim Form Case number: Contact date: Start date: Please make any necessary corrections to the information below, print or verify your VIN number and lienholder/leasing company information at the bottom of this page, and complete the missing information in Section 4 on the next page (attach additional sheets as needed). SECTION 1: CUSTOMER INFORMATION Titled owner: Mailing address: City: Day phone: ( Fax: ( ) ) Evening phone: ( E-mail address: ) State: Zip code: Cell phone: ( ) SECTION 2: VEHICLE INFORMATION Make: Model: Year: Current mileage: Name(s) that appears on the vehicle title: Selling dealer/city/state: Primary Servicing dealer/city/state: Acquired as new used demo leased Is the vehicle in your possession? Mileage at purchase/lease: First repair attempt mileage: Number of vehicles registered in California Transmission type: by vehicle owner/lessee: Automatic Manual yes no Date of accident: yes no Purchase/lease date: First repair attempt date: How often is the vehicle used for business purposes (percentage): % Has the vehicle been in an accident/had body damage? Description of damage: SECTION 3: DESIRED OUTCOME (Describe what you want done to resolve your concern) Please complete the missing information in the box below and on page 2. VEHICLE INDENTIFICATION NUMBER __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Page 1 of 2 Lienholder/Leasing Company ________________________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SECTION 4: VEHICLE PROBLEMS (List primary problem first) # of repair attempts List the date, mileage, and days out of service for each repair attempt 4/23/06 3,500 miles 5 days 6/10/07 12,700 miles 1 day Does the problem exist now? Problem Example: A/C won't cool properly Servicing dealer(s) Any Dealer, Inc. 2 yes Total days out of service for all problems: ________ I am submitting this dispute for resolution in the BBB AUTO LINE program, and I agree to arbitrate the dispute under the BBB AUTO LINE Arbitration Rules. Please mail or fax this completed form with copies of all available repair orders, your vehicle registration, your sales agreement or lease agreement, and any other relevant documents (e.g., written correspondence with the manufacturer, etc.) to: BBB AUTO LINE 4200 Wilson Blvd., Suite 800 Arlington VA, 22203-1838 Fax: 703-247-9700 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Signature of Titled Owner(s) ______________________________ _ Date ________________
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