NotSeenClaimForm

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

Use this form to submit a claim under the Vargas Settlement to receive a one-time cash payment of $20 if you are a Class Member and:

I. 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

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?

Has Ford Motor Company already repurchased your Class Vehicle?

Yes No

Have you already received one or more awards for a Software Flash Claim or Transmission Hardware Claim as outlined in Sections II.B and II.C of the Settlement Agreement?

Yes No

II. Ford Dealer Visit

Please enter the date of the Service Visit on which a Ford Dealer refused to make hardware or software repairs because the Dealer claimed there was nothing wrong with the vehicle:

Service Visit Date

Please enter the mileage on the Class Vehicle at the time of the above Service Visit:

Mileage

Please provide the name and address of the Ford Dealer that refused to make repairs during the above Service Visit:

Dealer Information

III. Affirmation I attest to and affirm under penalty of perjury that the information stated above is accurate to the best of my knowledge, and that I owned or leased the Class Vehicle at the time of the Service Visit on which this claim is based.

Specifically, I attest to and affirm under penalty of perjury that I experienced Transmission problems with the Class Vehicle with VIN identified in Section I above and sought relief within 7 years or 100,000 miles of delivery of the Class Vehicle to the first retail customer (whichever occurred first), that the Ford Dealer identified in Section II above refused to make hardware or software repairs because the Dealer claimed there was nothing wrong with the vehicle, and that the Ford Dealer did not subsequently make hardware or software repairs.

Required

Vargas v. Ford Motor Company

Claim Form For Cash Payment To Customers Turned Away By Ford Dealers