FOR NCDS USE TOYOTA Customer Claim Form CASE NUMBER: CUSTOMER NAME AND ADDRESS Mr. First name MILast name Mrs. Street address Ms.
City State Zip Code Day phone Evening phone Fax VEHICLE INFORMATION Name(s) that appears on the vehicle title: Is this a leased vehicle: Yes ¡ No ¡ Delivery Date: / / If yes, lessor 9s name and address: Make: Model: Year: Current mileage: Vehicle Identification Number: Selling dealer and address: Dominant Servicing Dealer: VEHICLE PROBLEM(S) (Attach legible copies of applicable repair orders or other documents that support your complaint) Problem List dealer(s) which have repaired or attempted repair (include city & state). List the date, mileage, and repair order number for each repair attempt. Does the problem currently exist?
(Circle) Example: A/C won 9t cool properly Autoworld, Inc Anytown, VA 4/23/99 3,500 miles #B73540 Yes No Yes No Yes No Yes No Yes No Yes No Has the vehicle been involved in an accident? YES NO If YES, give date of accident: Specify damaged area: Resolution Sought: X SIGNATURE(S) DATE Return all copies of this form to: National Center for Dispute Settlement P.O. Box 688 Mt.
Clemens, MI 48046 ... more. less.