All fields marked with a red asterisk (*) are mandatory and must be filled out in order to receive further information.

* Name:
* Email:
Address:
City:
State:
Zip:
County:
* Phone:
Occupation:
* Have you consulted an attorney regarding these facts?	Yes    No
* If so, who?
With what type of vehicle are you having a problem?
* Year:
* Make:
* Model:
* VIN:
Was the vehicle leased or purchased?	Leased Purchased
* When was the car leased or purchased?
* Did you buy or lease this vehicle new or used?	New Used
How much did it cost?
* From whom did you purchase the vehicle?
* What county is the Dealership in?:
Who was the salesman?
Who was the finance manager?
List any other employees of the Dealership with whom you have spoken and their position
* Who was with you at the Dealership?
* What company financed the vehicle?
Are your payments current?
What is the current payoff of the loan?
Did the vehicle come with a manufacturer"s warranty?	Yes No
Did the vehicle come with an extended warranty?	Yes No
* What was the mileage of the car at time of purchase?
* What was the mileage on the car when the dealer or manufacturer was first notified of the problem(s)
What is the current mileage?
* Has the vehicle been in the shop for three or more repairs for the same problem which is currently unresolved?	Yes No
* Does the unresolved problem affect the use value or safety of the vehicle?	Yes No
If so, how?
Identify the problem area of the car.	Engine Transmission Suspension Paint Other
* Describe the unresolved problems you are having:
What efforts have you made to resolve your problem:
* Have you spoken with a Manufacturer Representative?	Yes No
* Have you gone through the manufacturer's arbitration program?	Yes No
* How do you want this problem resolved?
* Do you feel you have been the victim of fraud?	Yes No
All fields on this portion of the online form are required if you said "Yes" to the question above.
Before signing the contract with the Dealership, did an employee of the Dealership make any false statements?	Yes No
Please list all false statements made to you.
Who heard these statements?
Has the vehicle been wrecked?	Yes No
What evidence do you have that the vehicle has been wrecked?
Has the Odometer been rolled back?	Yes No
Have you received a copy of the title history?	Yes No