ABOUT YOUR VEHICLE:

1. Year:
2. Make:
3. Model:
4. Date of Purchase (month/date/year):
5. Dealer name:
6. Dealer location:
7. Is the vehicle you purchased:
   New? Used?
8. Do you use this car for business or personal use?
   Business Personal
   If Business use, what percentage of total mileage? % (Commuting is NOT business use.)

ABOUT YOUR PROBLEMS:

1. How many times has your vehicle been in the repair shop for work?
2. Does the defect still exist? Yes No
3. How many calendar days has your vehicle been out of service because of repair work?
4. Do you have repair orders to verify the repair attempts? (If not, please get them from your dealer.) Yes No
5. Please list any significant problem(s) that currently exists with your vehicle for which you have 3 or more repair orders:
6. Any communication with the manufacturer? Yes No
   Written letter? Yes No
   Date received by manufacturer (month/date/year):
   Inspection by factory rep? Yes No
   Date (month/date/year):
7. Have you demanded a refund? Yes No

Please provide any additional information you would like to add: