Toll Free: 1-800 US LEMON® (1-800-875-3666)

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Warranty/Lemon Law - Free Case Review

Lemon Law Main Page
We handle claims in AZ, CA, FL, IL, IN, KY, MN, MO, NV, OH, WI and DC, visit our Lemon Law Website www.yourlemonlawrights.com
If you have a lemon in another state visit www.lemonlawamerica.com

Please complete the form below. Required fields are marked with an asterisk (*).

THE INFORMATION GIVEN IN THIS FORM IS PRIVATE AND WILL NOT BE DISSEMINATED TO ANYONE NOR SOLD OR "RE-USED" FOR ANY PURPOSE IN THE FUTURE

Your Contact Information...

*First Name:

*Last Name:

City:

State:

Zip:

** Home Phone:

** Work Phone:

** Cell/Pager:

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Email:

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What is the best time to reach you?

daytime (9a-5p) evening (after 5p)

Tell us about your vehicle...

Did you finance your vehicle?:

Yes No

Did you purchase your vehicle on an employee purchase plan discount?:

Yes No

Year / Make:

Bought:

Dealer:

Date of purchase:

State of Purchase:

Mileage at purchase:

Mileage now:

Type of warranty received:

Fraud Information

Yes No	A.) Do you suspect the odometer may have been tampered with in some way?
Yes No	B.) Was there a problem or issue with the financing of your vehicle?
Yes No	C.) Do you think your vehicle may have been involved in an accident before you purchased it?
Yes No	D.) Were there other misrepresentations about your vehicles prior history?
	Location of vehicle today?:
	Additional Fraud Information:

Repair Information

Engine, Transmission:	none 1 2 3 4 5 or more
Suspension, Steering & Brakes:	none 1 2 3 4 5 or more
Electrical System:	none 1 2 3 4 5 or more
Body, Paint & Interior:	none 1 2 3 4 5 or more
Heating / AC:	none 1 2 3 4 5 or more
Leaks:	none 1 2 3 4 5 or more
Noises:	none 1 2 3 4 5 or more
Other:	none 1 2 3 4 5 or more

Total number of times vehicle has been in for repair:

Total number of days vehicle has been in for repair:

Additional Information:

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