Ford Dual Clutch Transmission Class Action Lawsuit

CLAIM FORM FOR REIMBURSEMENT FOR CLUTCH REPLACEMENT

Use this form to submit a claim under the Romeo Settlement for reimbursement for a clutch replacement if you can satisfy all of the following criteria:

Your Class Vehicle was manufactured after June 5, 2013;
A Ford dealer replaced the clutch (part number 7B546 Disc Asy-Clutch) in your Class Vehicle twice within the 5-year/100,000 kilometre powertrain warranty;
A Ford dealer performed appropriate diagnostic procedures and determined that a third clutch replacement was necessary; AND
You paid a Ford dealer to replace the clutch a third time within 7 years/160,000 kilometres of delivery of the Class Vehicle to the first retail customer, whichever occurs first.

Background Information

First Name

Last Name

Business Name (if applicable)

Please check if a non-Canadian address

Primary Address

Primary Address Continued

City

Province

Postal Code

Foreign Country

Email Address

Telephone Number (Home)

Telephone Number (Work)

Have you sued Ford Motor Company or Ford Motor Company of Canada, Limited in a court in relation to the PowerShift Transmission or the DPS6 Transmission in your Class Vehicle?

Yes No

Have you commenced a proceeding under CAMVAP in relation to the PowerShift Transmission or the DPS6 Transmission in your Class Vehicle?

Yes No

Vehicle Information

Class Vehicle VIN

Class Vehicle Model

Class Vehicle Model Year

Date you purchased or leased your Class Vehicle

Do you still own or lease the Class Vehicle?

Yes No

What date did you sell or return the vehicle?

Clutch Replacements

First Service Visit

Please enter the date of the first Service Visit on which a Ford dealer replaced the clutch in your vehicle (part number 7B546 Disc Asy-Clutch):

First Service Visit Date

Please upload the service records for this Service Visit below.

Second Service Visit

Please enter the date of the second Service Visit on which a Ford dealer replaced the clutch in your vehicle (part number 7B546 Disc Asy-Clutch):

Second Service Visit Date

Please upload the service records for this Service Visit below.

Third Service Visit

Please enter the date of the third Service Visit on which a Ford dealer replaced the clutch in your vehicle (part number 7B546 Disc Asy-Clutch):

Third Service Visit Date

Please upload the service records for this Service Visit below and any additional documentation required to establish the amount you paid to a Ford dealer for the parts and labor for the third clutch replacement.

Proof of Vehicle Ownership At Time of Transmission Hardware Replacements

Do all of the service records you submitted in support of this claim identify you as the person requesting the repairs?

Yes No

Upload Supporting Documentation

Maximum file size: 5 mb

Allowed file types: .jpg, .jpeg, .tif, .tiff, .gif, .png, .pdf, .xlsx

Declaration and Affirmation Under Oath I declare and affirm under oath that the information stated above is accurate to the best of my knowledge, that the documentation I have provided to support this claim is authentic, and that I actually owned or leased the Class Vehicle at the time of each Clutch Replacement on which this claim is based.

If the information or documentation you provide is incomplete, your claim may be rejected.

Required