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Defective Auto

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Defendant:
(who caused the harm?)

Defective Automobiles

*Describe your complaint:
(briefly describe the damages you have suffered)

*Make of vehicle:

*Model of vehicle:

*Year of vehicle:

*New or Used?

*Do you have record of all previous maintenance check ups?

Yes No

Dealership name:

Dealership location:

*First name:

*Last name:

*Email address:

*Confirm email address:

*Phone number(s):

*Zip/Postal Code:

Best time & way to contact you:

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