Vargas v. Ford Motor Company

Clutch Claim Form

Use this form to submit a claim under the Vargas 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/60,000 mile 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/100,000 miles of delivery of the Class Vehicle to the first retail customer, whichever occurs first.

PLEASE NOTE: Claims will not be processed, and no cash payments will be issued, until the Settlement has received Final Approval and all appeals from the order approving the Settlement have been resolved or the appeal periods have expired. Please consult the Settlement Website for updates regarding timing.

VIN Lookup

Use this VIN lookup to determine if the vehicle was manufactured after June 5, 2013.

VIN

Background Information

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)

Are you an employee of Ford Motor Company?

Yes No

Are you an officer or director of a Ford Dealer?

Yes No

Has Ford Motor Company already repurchased your Class Vehicle?

Yes No

Have you signed and returned to Ford a release of your claims based on the PowerShift Transmission in your Class Vehicle?

Yes No

Class Vehicle VIN

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

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

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

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

Proof of Vehicle Ownership At Time of Clutch Replacements

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

Yes No

If you answered “yes,” you do not need to submit any additional evidence that you owned the Class Vehicle at the time of the repairs for which you seek reimbursement.

If you answered “no,” please attach one of the following sets of documents establishing that you owned or leased the vehicle at the time of all the repairs that form the basis for your claim:

submit (a) a vehicle title, vehicle purchase agreement, or vehicle lease agreement that identifies you as the vehicle owner, purchaser, or lessee at the time of the earliest Service Visit that forms the basis for your claim, AND (b) vehicle registration identifying you as the vehicle owner as of the date of the latest Service Visit that forms the basis for your claim (or as of a later date); OR
for every repair that forms the basis for your claim, submit either (a) a repair record that identifies you as the person who requested the repair, OR (b) a vehicle registration that identifies you as the vehicle owner as of the date of each repair.

Upload Supporting Documentation

Please upload:
(1) service records for all three Service Visits on which a Ford dealer replaced the clutch in your vehicle,
(2) any additional documentation required to establish the amount you paid to a Ford dealer for the parts and labor for the third clutch replacement, and
(3) documentation necessary to prove that you owned the vehicle at the time of the Clutch Replacements (unless all of your service records identify you as the person requesting the repairs).

Maximum file size: 30 mb

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

Uploaded Files

Affirmation I attest to and affirm under penalty of perjury 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.

Required