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Print Form FOR NCDS USE CASE NUMBER TOYOTA Customer Claim Form CUSTOMER NAME AND ADDRESS Mr. First name MI Last name Street address Ms. City State Day phone Zip Code Evening phone Email address Fax Preferred contact location VEHICLE INFORMATION Name s that appears on the vehicle title Is this a leased vehicle Yes No Delivery Date / If yes lessor s 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. Example A/C won t cool properly Autoworld Inc Anytown VA List the date mileage and repair Does the problem currently order number for each repair attempt. exist Check one Has the vehicle been involved in an accident If YES give date of accident B73540 3 500 miles 4/23/99 YES NO Specify damaged area Resolution Sought Return all copies of this form to National Center for Dispute Settlement P. City State Day phone Zip Code Evening phone Email address Fax Preferred contact location VEHICLE INFORMATION Name s that appears on the vehicle title Is this a leased vehicle Yes No Delivery Date / If yes lessor s 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. Example A/C won t cool properly Autoworld Inc Anytown VA List the date mileage and repair Does the problem currently order number for each repair attempt. Example A/C won t cool properly Autoworld Inc Anytown VA List the date mileage and repair Does the problem currently order number for each repair attempt. exist Check one Has the vehicle been involved in an accident If YES give date of accident B73540 3 500 miles 4/23/99 YES NO Specify damaged area Resolution Sought Return all copies of this form to National Center for Dispute Settlement P. City State Day phone Zip Code Evening phone Email address Fax Preferred contact location VEHICLE INFORMATION Name s that appears on the vehicle title Is this a leased vehicle Yes No Delivery Date / If yes lessor s 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. Example A/C won t cool properly Autoworld Inc Anytown VA List the date mileage and repair Does the problem currently order number for each repair attempt. exist Check one Has the vehicle been involved in an accident If YES give date of accident B73540 3 500 miles 4/23/99 YES NO Specify damaged area Resolution Sought Return all copies of this form to National Center for Dispute Settlement P. .

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