Ford Dual Clutch Transmission Class Action Lawsuit

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

Use this form if you have already submitted at least one Transmission Hardware Replacement claim that was approved by the Claims Administrator, and you wish to submit a claim for a subsequent Transmission Hardware Replacement.

Claim ID No. of Your Existing Claim (8 Digit Claim #, ex: FDQ-99999999)

FDQ-

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)

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

Note: Previous awards for Software Flashes shall be deducted from any award made for a Transmission Hardware Replacement

Vehicle Information

Class Vehicle VIN

Class Vehicle Model

Class Vehicle Model Year

Do you still own or lease the Class Vehicle?

Yes No

What date did you sell or return the vehicle?

Transmission Hardware Replacements

Please enter the date of the Service Visit on which the qualifying Transmission Hardware Replacement that is the basis of this claim was performed

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.

Upload Supporting Documentation

If you are identified as the person requesting the repair on the service records for this Service Visit, you do not need to attach other proof that you owned the Class Vehicle as of the time of this Service Visit. If you are not identified as the person requesting the repair, you must attach a vehicle registration identifying you as the vehicle owner as of the date of this Service Visit (or as of a later date).

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