Vehicle Repurchase Or Replacement Request Form printable pdf download

VEHICLE REPURCHASE OR REPLACEMENT REQUEST

As detailed below, this constitutes my request as a consumer for a repurchase or a replacement vehicle,

pursuant to the Georgia Lemon Law, O.C.G.A. Section 10-1-784(b)(1).

Vehicle Make _____________________________ Model _______________________

Year ___________

Vehicle identification number (VIN)/

Name/address of selling/leasing dealer_______________________________________________________

______________________________________________________________________________________

Vehicle was: ____ purchased ____ leased (check one)

Date of delivery ________________

Odometer reading on delivery date __________ Odometer reading at first repair visit for defect__________

Date vehicle registered in GA if bought/leased in another state ________________

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Date final repair attempt request was received by manufacturer _____________________

If the manufacturer designated a reasonably accessible repair facility within seven (7) days from

the receipt of your final repair attempt request, please list the following:

Date of final repair __________ and name of the facility where the final repair attempt took place:

_______________________________________________________________________________

Was the defect corrected on the final repair attempt? ___________ Yes ___________ No

AND/OR

Date ___________ and odometer reading _____________ on 30th day vehicle was out of service for repair

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I am requesting that you ____ replace ____ repurchase (check one) the vehicle described above

within 20 days from the receipt of this notice. My contact information is:

Consumer name ____________________________________________ Home phone _________________

Street address _____________________________________________ Cell phone ___________________

City/State/ZIP _____________________________________________ Work phone __________________

Consumer signature ________________________________________ Today's date _________________

Instructions to consumer: Remember to make a copy for your records and send the original by overnight

mail delivery or certified mail, return receipt requested, to the manufacturer at the address provided

in your owner’s manual. If your vehicle is a motor home, you must send notices to all known

manufacturers.

Also, for our records, please send a copy to the Georgia Department of Law, Consumer Protection Unit at

the address listed on the first page, or fax it to us at 404-656-3569.

Vehicle Repurchase Or Replacement Request Form