Form Cns 006 - Request For Arbitration Form - New York State Attorney General'S Office Page 2

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Office Use Only:
Case No.
__________________
Referred To NYSDRA ___________
Filing Date
__________________
NEW YORK STATE ATTORNEY GENERAL=S OFFICE
ERIC T. SCHNEIDERMAN, ATTORNEY GENERAL
NEW YORK NEW CAR LEMON LAW ARBITRATION PROGRAM
REQUEST FOR ARBITRATION FORM
CONSUMER INFORMATION
1.
Name:
_______________________________________________________________
Address:
_______________________________________________________________
City:
____________________________ State:_______ Zip:_________________
Phone: Home (______)_____-_______________
Work:(______)_____-_______________
E-mail address: _______________________________________________________________
[ ]
I prefer to send/receive communications by e-mail rather than be regular mail.
VEHICLE INFORMATION (Attach Copy of Your Bill of Sale or Lease)
2.
Manufacturer: ______________________________________________________________
(GM, Ford, Chrysler, Toyota, Winnebago, etc.)
3.
Year: _________
Make: _______________
Model: __________________________
(ex. Chevrolet, Dodge)
(ex. Cavalier, Caravan)
4.
Vehicle Identification Number (VIN):____________________________________________
5.
Date of delivery?_________ Mileage at delivery:______ Current Mileage: ____________
6.
Did you purchase or lease your vehicle in New York? .................... Yes[ ] No[ ]
[ ] I purchased my vehicle.
[ ]
I leased my vehicle.
7.
Is your vehicle registered in New York?........................................
Yes[ ] No[ ]
8.
Is your vehicle primarily used for personal, family or
household purposes? ...............................................................
Yes[ ] No[ ]
9.
Do you still own or lease your vehicle? .......................................... Yes[ ] No[ ]
1

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