Ford Dual Clutch Transmission Class Action Lawsuit

CLAIM FORM FOR FIRST REQUEST FOR CASH PAYMENTS/OWNER APPRECIATION CERTIFICATES FOR TRANSMISSION HARDWARE REPLACEMENTS

Use this form to submit YOUR FIRST CLAIM under the Romeo Settlement for cash payments or Owner Appreciation Certificates for repeated Transmission Hardware Replacements, which means three or more replacements of parts on the following list:

7B546 Disc Asy-Clutch	7Z369 Control Mod Trans (TCM)	7052 Oil Seal-Trans Rear
7000 Transmission Asy-Aut	7C604 Motor-Frt Clutch	7A508 Rod-Cl/Slave Cyl Pus
6K301 Seal/RetC/Shft Oil	7060 Shaft/Bshg Asy-Out	7048 Seal-Input Shaft Oil
7515 Lever Asy-Clutch Rel

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

Please select the form of payment you are requesting

Cash Payment (CAD Cheque) OR Owner Appreciation Certificate

Have you already received one or more awards for a Software Flash claim?

Yes No

Number of Awards Received

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?

Transmission Hardware Replacements

First Service Visit

Please enter the date of the first Service Visit on which a qualifying Transmission Hardware Replacement was performed.

First Service Visit Date

Please select which Transmission Hardware part was replaced on this Service Visit (if more than one of these parts was replaced, you only need to select one part number)

Transmission Hardware Part

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 qualifying Transmission Hardware Replacement was performed.

Second Service Visit Date

Please select which Transmission Hardware part was replaced on this Service Visit (if more than one of these parts was replaced, you only need to select one part number)

Transmission Hardware Part

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 qualifying Transmission Hardware Replacement was performed.

Third Service Visit Date

Please select which Transmission Hardware part was replaced on this Service Visit (if more than one of these parts was replaced, you only need to select one part number)

Transmission Hardware Part

Please upload the service records for this Service Visit below.

Additional Service Visits

Additional Service Visit Date

Transmission Hardware Part

Please upload the service records for this Service Visit below.

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