Ford Dual Clutch Transmission Class Action Lawsuit

CLAIM FORM FOR FIRST REQUEST FOR CASH PAYMENTS FOR SOFTWARE FLASHES

If you have already submitted at least one Transmission Hardware Replacement claim that was approved by the Claims Administrator, STOP HERE. You are no longer eligible to submit a Software Flash claim.

Use this form to submit YOUR FIRST CLAIM under the Romeo Settlement for cash payments for repeated Software Flashes, which means at least one of the following labor codes or labor descriptions was performed on each of three or more Service Visits:

110333A	110405A	110513A	110524A	110902A
131102A	131104A	131108A	131109A	131110A
150090M	150090N	150090P	150090Q	150120H
160109C	160109D	160129A	MT131102	R08101
14M01DD	14M01E	14M01EE	14M01GG	14M01H
120104A	130405A	130405B	130405C	130406A
130904A	130904B	130904C	140131A	140131B
140131C	140131D	140131E	150017A	150090H
150090L	150120L	150120M	150120N	150120P
150120Q	160044A	160109A	160109B	R08102
R11021	14M01A	14M01AA	14M01BB	14M01C
14M01CC	14M01D	14M01L	14M01M	14M01N
14M01P	14M01Q	14M02B	14M02C	14M02D
Other Labor Description or TSB number

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?

Software Flashes

First Service Visit

Please enter the date of the first Service Visit on which a qualifying Software Flash was performed.

Service Visit Date

Please select the labor code or labor description for the Software Flash performed on this Service Visit (if more than one Software Flash was performed, you only need to select one labor code or labor description).

Labor Code

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 Software Flash was performed.

Service Visit Date

Labor Code

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 Software Flash was performed.

Service Visit Date

Labor Code

Please upload the service records for this Service Visit below.

Additional Service Visits

Additional Service Visit Date

Labor Code

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