Form Vs-35 - Complaint Report -
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1
2New York State Department of Motor Vehicles
VS-35 (3/11)
FOR OFFICE USE ONLY
Division of Vehicle Safety
Facility
COMPLAINT REPORT
Number
C.O. Case
INSTRUCTIONS: (Before filing your complaint, please attempt to settle this matter with the facility.)
Number
Check the appropriate box to show the type of complaint involved.
CSR
Vehicle repair
Vehicle inspection
Vehicle purchase
We can only accept complaints about repairs up to 90 days or 3,000 miles (whichever
Region
County
comes first) after the date repairs were completed. The only exception is a written warranty that
may exceed these time and/or mileage limits.
R.O. Case
PLEASE PRINT OR TYPE ALL ENTRIES AND USE BLACK INK
Number
Your
Name of
Name
Facility
Address - Number
Address - Number
and Street
and Street
City
State
Zip Code
City
State
Zip Code
Telephone Number (Include area code)
Telephone Number
Home (
)
Work (
)
(Include area code) (
)
Vehicle Identification
Identification Number
Number
of Facility
Vehicle Year, Make, Model
Plate
Cylinders
Name of Person with whom
Number
you dealt at facility
Date of repair/inspection/purchase
Odometer reading at time of repair/
Today’s
Current odometer reading at time
inspection/purchase
Date
of filing the complaint
/
/
/
/
ANSWER QUESTIONS BELOW AND/OR ON PAGE 2 OF THIS FORM THAT APPLY TO YOUR COMPLAINT
A. Repair Complaint
1. Describe the specific reason you brought the vehicle to the repair shop: ____________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2. Did you ask for a written estimate of the parts and labor necessary to do the repair?
Yes
No
If Yes, attach a copy of the estimate.
3. What was the actual cost of repair? $____________________ (Attach invoice)
4. Before the repair was performed, did you ask that any replaced part be returned to you?
Yes
No
If Yes, do you have the replaced parts?
Yes
No
5. Did you authorize any additional repairs?
Yes
No
Specify ______________________________________________________
6. Were you charged for work not performed?
Yes
No Explain ____________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
7. Was any unnecessary or unauthorized work performed?
Yes
No
Specify __________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
8. Did you go to another facility to have the problem corrected?
Yes*
No
* If Yes, attach invoice and give us the following information about the facility:
Name _____________________________________________________________ Facility ID No. ______________________________
Street ________________________________________________________________________________________________________
City __________________________ State __________ Zip Code _____________ Telephone No. (
) ______________________
B. Inspection Complaint
1. Did the inspection station refuse to inspect your vehicle?
Yes
No
2. Did the inspection station refuse to give you an appointment date in writing?
Yes
No
3. Were you told or led to believe that repairs necessary to pass inspection had to be made at the same station?
Yes
No
4. How much were you charged for the inspection $___________________.
/
/
5. Inspection Certificate # _________________________
Expiration Date _________________________
6. Did you receive an inspection receipt?
Yes
No
If yes, attach a copy of the receipt.
PAGE 1 OF 2
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