STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION TRADE PRACTICES DIVISI ON, LEMON LAW UNIT AUTOMOBILE DISPUTE SETTLMENT

PROGRAM

REQUEST FOR ARBITRATION

INSTRUCTIONS 1. Read the entire Back In The Drivers Seat booklet before completing this application. We realize that 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 Department of Consumer Protection. DO NOT SEND CASH. The owner(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 owners manual, you must send written notification to the manufacturer at the address indicated in the warranty or owners manual of your intent to file a complaint under lemon law. Please provide a copy of the letter sent to the manufacturer with your Request for Arbitration. Submit the Request for Arbitration, required documents, and filing fee to: Department of Consumer Protection Automobile Dispute Settlement Program 165 Capitol Avenue, Room 110 Hartford, Connecticut 06106

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Request for Arbitration

OWNER(S) INFORMATION:
Name of Owner(s) Street Address City Telephone: (Indicate name if more than one owner) Home ( )

FOR OFFICE USE ONLY: CASE # RECEIVED COMPLETED

Page 1

State Work ( )

Zip Code

VEHICLE INFORMATION:

Year Make/Manufacturer Model Mileage at the time of purchase Current Mileage Is the transmission automatic or standard? Vehicle Identification Number: Purchase Date Delivery Date Contract Price Did you receive a manufacturers rebate? If yes, amount YES NO Was it deducted at the time of purchase or sent to you after the vehicle was purchased? If the vehicle is financed and you were to prepay your loan, what is the current payoff * balance of the loan? $ ________________________ as of _____________________________(date). (* This differs from the balance of your loan. This
information is available from your lending institution.)

Date last payment made Selling Dealership Street Address City Are you the original owner? YES

State NO

Zip Code

If no, name and address of the original owner(s), if known

LEASED INFORMATION:

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.

Name of Leasing Company Street Address City State Telephone ( ) What is the payoff balance of the lease without purchase option? What Is the amount of the purchase option?

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 manufacturer, provide a copy of the correspondence.

Request for Arbitration

FIRST REPAIR:
FROM (Date): Number of days the vehicle was in the shop for this service Repair Order Number Servicing Dealer Street Address City State Zip Code Mileage TO (Date):

Page 2

Was the repair covered by the terms of the manufacturers new car warranty? Amount you paid for this repair including a deductible, if any. Describe the nature of the problem(s):

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.

Request for Arbitration

SECOND REPAIR:
FROM (Date): Number of days the vehicle was in the shop for this service Repair Order Number Servicing Dealer Street Address City State Zip Code Mileage TO (Date):

Page 3

Was the repair covered by the terms of the manufacturers new car warranty? Amount you paid for this repair including a deductible, if any. Describe the nature of the problem(s):

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.

Request for Arbitration

THIRD REPAIR:
FROM (Date): Number of days the vehicle was in the shop for this service Repair Order Number Servicing Dealer Street Address City State Zip Code Mileage TO (Date):

Page 4

Was the repair covered by the terms of the manufacturers new car warranty? Amount you paid for this repair including a deductible, if any. Describe the nature of the problem(s):

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.

Request for Arbitration

FOURTH REPAIR:
FROM (Date): Number of days the vehicle was in the shop for this service Repair Order Number Servicing Dealer Street Address City State Zip Code Mileage TO (Date):

Page 5

Was the repair covered by the terms of the manufacturers new car warranty? Amount you paid for this repair including a deductible, if any. Describe the nature of the problem(s):

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.

For any additional repairs, please include a separate page for each repair and follow the same format.

Request for Arbitration

Answer the following questions.

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1. What is the total number of days the vehicle was at the dealership by reason of repair during the first 18,000 miles or two (2) years, whichever occurred first? ___________ 2. What is the total number of days the vehicle was at the dealership by reason of repair during the first 24,000 miles or two (2) years, whichever occurred first? ___________ 3. What are the total number of days the vehicle was at the dealership by reason of repair from the purchase date to the present? _________________________________ 4. Are you currently driving the vehicle? YES NO YES YES If no, explain. NO NO If yes, explain.
If yes, please IF YOU PURCHASED OR LEASED THE VEHICLE ON OR AFTER OCTOBER 1, 1998 THIS QUESTION IS APPLICABLE.

IF YOU PURCHASED OR LEASED THE VEHICLE ON OR BEFORE SEPTEMBER 30, 1998 THIS QUESTION IS APPLICABLE.

5. Were you ever refused service of the vehicle by the dealer? 6. Has the vehicle ever been in an accident or sustained damage?
explain.

Indicate the date of the incident and include a copy of estimates, repair orders and the accident report. Has the damage been repaired? YES NO If yes, where was the vehicle repaired? ______________________________________ Amount of repairs $______________ Were the repairs covered by the manufacturers new car warranty? YES NO

7. What is the period of the warranty? (months/mileage) Basic New Car Warranty: ___________ months/__________ miles Power Train Warranty: ___________ months/__________ miles Extended Warranty: ___________ months/__________ miles From whom was the extended warranty purchased? ________________________________________________________________________ ________________________________________________________________________ Date of purchase __________________ Purchase Price _________________ Include a copy of the extended warranty with your Request to Arbitrate.

Request for Arbitration

7. Have you notified the manufacturer (not the dealer) about the defect(s)? ____ By telephone In Writing . Include copies of all written correspondence. If yes, please complete the following: Name (Title) and Address of Contact. Date of Contact Result of Contact.

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Name (Title) and Address of Contact. Date of Contact Result of Contact. 8. Have you participated in any other arbitration or mediation program regarding this vehicle? YES NO Did you accept the award?__________ If yes, provide a copy of the award. 9. Select one of the following types of hearings. (Refer to the Back to the Drivers Seat booklet for an explanation of oral and documentary hearings.)

Oral Hearing. If possible, bring your vehicle to the scheduled

hearing.

of your vehicle, one will be scheduled after the hearing.

Documentary Hearing. If the arbitrators order an inspection

10. If you intend to be represented by an attorney, complete the following. All correspondence will be directed to your attorney. Attorneys Name Street Address City State Zip Code Telephone Number ( )

Request for Arbitration

Page 8

11. The arbitration panel will ultimately determine a fair and equitable decision. Please select one of the following options to indicate what you believe would be a fair resolution. A) *REPLACEMENT with an identical or comparable vehicle.
Include information relative to factory or dealer installed options, design characteristics, or color choices that would be essential in any replacement vehicle; or,

*possibly not applicable to leased vehicles

B)

REFUND

of the contract price. Note: Arbitrators may deduct an allowance for consumers use of the vehicle. Indicate f applicable, why you feel you should not be assessed a mileage usage fee for the miles you were able to drive the vehicle. Finance charges are normally reimbursed only for he days the vehicle was in for repair. Explain if applicable, why you feel you should be reimbursed for any finance charges; or,.

C) OTHER

12. TO BE ELIGIBLE FOR AN AWARD, there must be a substantial loss of use, safety or value.

Explain how the substantial loss of use, safety or value of this vehicle has been impaired. Briefly, describe the current condition of the vehicle and list any defect (s) that still exist.

Request for Arbitration

13.

Page 9

List any additional reimbursements you are seeking. Indicate why you feel the panel should award the reimbursement. Examples include: towing charges, rental costs, options or modifications, costs or estimates regarding property or injury to a person, attorneys fees, cost of an extended warranty, out of pocket cost for warranty repairs including any deductible amounts you were required to pay, etc.

Item: Date: Cost: Reason: Item: Date: Cost: Reason: Item: Date: Cost: Reason: Item: Date: Cost: Reason: Item: Date: Cost: Reason: Item: Date: Cost: Reason:

Request for Arbitration

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14. Have you modified the vehicle in any way? YES NO (Do not include manufacturer covered options that were on your vehicle at the time of purchase.) If YES, complete the following. Include receipts and warranty information with the application. Modification: Facility where installed Work Order Number Warranty issued by dealer, manufacturer, other Cost: Modification: Facility where installed Work Order Number Warranty issued by dealer, manufacturer, other Cost: Modification: Facility where installed Work Order Number Warranty issued by dealer, manufacturer, other Cost:

Date of Installation Mileage:

Date of Installation Mileage:

Date of Installation Mileage:

15. List any routine maintenance performed on this vehicle (oil changes, tune-up, etc.). If you performed your own maintenance, you are still required to complete the list. Type of Maintenance Facility Work Order Invoice Number Date Type of Maintenance Facility Work Order Invoice Number Date Type of Maintenance Facility Work Order Invoice Number Date

Cost

Mileage

Cost

Mileage

Cost

Mileage

Request for Arbitration

AGREEMENT TO ARBITRATE

Page 11

I submit this dispute to the Department of Consumer Protection, Automobile Dispute Settlement Program for arbitration. Said arbitration shall be governed in all aspects by the provisions of Section 42-181 of the Connecticut General Statutes and the regulations promulgated thereunder, including the scope of the issues submitted, eligibility criteria, remedies and operating procedures. I understand that the arbitration award is equally binding as to the Lemon Law rights of both parties. According, once the award is rendered, I understand that either party to the dispute may apply to the Superior Court to have award confirmed, vacated, modified or corrected as provided in Section 42-181, 52-417, 52-418, 52-419, and 52-420 of the Connecticut General Statutes. I understand that I may be represented by private legal counsel in any arbitration hearing and that if I choose to be so represented I must notify the Department of Consumer Protection of the name, address and telephone number of such counsel at least two days prior to the date of the arbitration hearing. If the attorney information appears on this application, no additional notification is required. I understand that I shall have no contact, other than at the scheduled arbitration hearing, with any arbitrator assigned to this dispute and that all necessary communication shall be addressed to the Department of Consumer Protection. I verify that the information provided is true, accurate and complete to the best of my knowledge. I understand that the penalty for willfully making a false statement is a maximum fine of one thousand dollars ($1,000.00) and/or one year imprisonment (Connecticut General Statutes, Section 53a-157). Owner Owner
STATE OF COUNTY OF

Date Date

Subscribed and sworn to before me on this _________day of __________, 20____. ________________________________ Commissioner of the Superior Court or, Notary Public My Commission Expires: ___________

Request for Arbitration

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Submit legible copies. Do not write on the back of pages. Do not staple pages together. Submit additional information on 8-1/2 x 11 paper.

CHECK LIST

r r r r r r r r r r

Is the application notarized? Did you include the $50.00 filing fee payable to the Department of Consumer Protection? Copy of all work orders Copy of the original sales contract Copy of the motor vehicle registration Copy of the finance agreement, if financed Copy of the title, if the vehicle is not financed Copy of the ENTIRE manufacturers new car warranty book, (not owners manual), including the front cover that has your name, address, and Vehicle Identification Number. Do not submit the original book. A copy of the written notification to the manufacturer, if required.

Copy of any receipts for: 3 routine maintenance 3 modifications to your vehicle 3 extended warranty 3 any items for which you are seeking reimbursement 3 repairs that are not covered by the manufacturers new car warranty 3 accident information: police report, correspondence with insurance company, etc. Leased Vehicles: r Copy of the lease agreement

copy of the certified or registered letter to the leasing company and a copy of the postal receipt

NOTICE: The public has the right to observe arbitration hearings. Documents submitted by consumers or manufacturers are public records. Hearings are held at: Department of Consumer Protection 165 Capitol Avenue, State Office Building Room 157 Hartford, Connecticut 06106