Vargas v. Ford Motor Company

CLAIM FORM FOR FIRST REQUEST FOR CASH PAYMENTS/VEHICLE DISCOUNT CERTIFICATES FOR TRANSMISSION HARDWARE REPLACEMENTS

Use this form to submit YOUR FIRST CLAIM under the Vargas Settlement for cash payments or Vehicle Discount 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

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.

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 given Ford a release of your claims based on the PowerShift Transmission in your Class Vehicle?

Yes No

Please select the form of payment you are requesting

Prepaid Cash Card Vehicle Discount Certificate

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?

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

Yes No

Number of awards

Transmission Hardware Replacements

Date of the first Service Visit on which a qualifying Transmission Hardware Replacement was performed

Part Number

Date of the first Service Visit on which a qualifying Transmission Hardware Replacement was performed

Part Number

Date of the first Service Visit on which a qualifying Transmission Hardware Replacement was performed

Part Number

Additional Service Visits

Date of the Service Visit on which a qualifying Transmission Hardware Replacement was performed

Part Number

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

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,” you need to attach one of the following sets of documentation to establish that you owned or leased the vehicle at the time of 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 each repair that forms the basis for your claim, submission of 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 that forms the basis for your claim.

Upload Supporting Documentation

Please upload service records for all Service Visits on which your claim is based on which a qualifying Transmission Hardware Replacement was performed on your vehicle, as well as documentation necessary to prove that you owned the vehicle at the time of the Transmission Hardware 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 Transmission Hardware Replacement on which this claim is based.

Required