Vargas v. Ford Motor Company

NOTICE OF INTENT TO PROCEED TO ARBITRATION

Claimant Identification

First Name

Middle Initial

Last Name

Please check if a non-U.S. address

Primary Address

Primary Address continued

City

State

Zip

Province

Postal Code

Country

Email Address

Phone (Home)

Phone (Work)

Arbitration

Will you be represented in arbitration by an attorney with respect to your Claim for Repurchase/Replacement or Breach of Express Warranty?

Yes

Preferred Method of Contact

VIN of your Class Vehicle

Date on which you purchased or leased your Class Vehicle

Do you still own or lease the vehicle identified?

Yes No

Remedy you intend to seek in arbitration

Repurchase or replacement of my vehicle because of PowerShift transmission problems
Breach of Ford’s New Vehicle Limited Warranty or extension thereof
Repair of my vehicle’s PowerShift transmission
Reimbursement for PowerShift transmission repairs I paid for
Extended service plan for my vehicle

Number of attempts you have made to have your PowerShift transmission repaired by Ford or its authorized dealer(s)

1-3 4 or more

Are you still having transmission problems with the vehicle?

Yes No

Briefly describe the problem

Additional Comments