Vargas v. Ford Motor Company

CLAIM FORM FOR FIRST REQUEST FOR CASH PAYMENTS FOR SOFTWARE FLASHES

Use this form to submit YOUR FIRST CLAIM under the Vargas Settlement for cash payments for repeated Software Flashes, which means at least one of the following labor codes or labor descriptions was performed on each of three or more Service Visits:

110333A	110405A	110513A	110524A	110902A
131102A	131104A	131108A	131109A	131110A
150090M	150090N	150090P	150090Q	150120H
160109C	160109D	160129A	MT131102	R08101
14M01DD	14M01E	14M01EE	14M01GG	14M01H
120104A	130405A	130405B	130405C	130406A
130904A	130904B	130904C	140131A	140131B
140131C	140131D	140131E	150017A	150090H
150090L	150120L	150120M	150120N	150120P
150120Q	160044A	160109A	160109B	R08102
R11021	14M01A	14M01AA	14M01BB	14M01C
14M01CC	14M01D	14M01L	14M01M	14M01N
14M01P	14M01Q	14M02B	14M02C	14M02D
Other Labor Description or TSB number

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

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 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?

Software Flashes

Date of the first Service Visit on which a qualifying Software Flash was performed

First Service Labor Code

Date of the second Service Visit on which a qualifying Software Flash was performed

Second Service Labor Code

Date of the third Service Visit on which a qualifying Software Flash was performed

Third Service Labor Code

Additional Service Visits

Date of the Service Visit on which a qualifying Software Flash was performed

Labor Code

Proof of Vehicle Ownership At Time of Service Visits

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 Service Visits for which you seek reimbursement.

If you answered “no,” you must attach one of the following sets of documents to establish that you owned or leased the vehicle at the time of the Service Visits on which your claim is based:

(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 on which your claim is based, AND (b) vehicle registration identifying you as the vehicle owner as of the date of the latest Service Visit on which your claim is based (or as of a later date); OR
for each Service Visit on which you base your claim, 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 Service Visit on which your claim is based.

Upload Supporting Documentation

Please upload service records for all Service Visits on which your claim is based on which a qualifying Software Flash was performed on your vehicle, as well as documentation necessary to prove that you owned the vehicle at the time of the Software Flashes (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 owned or leased the Class Vehicle at the time of each Service Visit and corresponding Software Flash on which this claim is based.

Required