INSTRUCTIONS FOR COMPLETING

THE USED CAR LEMON LAW

REQUEST FOR ARBITRATION FORM

To participate in the New York State Used Car Lemon Law Arbitration Program, you
must complete the attached form. Be as accurate and complete as possible. Please
attach copies of all relevant documents (including your purchase or lease agreement,
the NYS Used Car Warranty, all service or work orders relating to the problem for which
you seek this arbitration, and any correspondence between you and the dealer relating
to such problem). DO NOT SEND ORIGINAL DOCUMENTS. Sign and return the
completed form, together with your documents, to:

The New York State Attorney General's Office

120 Broadway -- 3rd floor
New York, NY 10271
Attention: USED CAR LEMON LAW ARBITRATION UNIT

The Attorney General's Office will review your form and advise you whether your claim
is accepted in the arbitration program. If the form is accepted, you will be notified by the
Attorney General's Office which will then forward your form and documents to the New
York State Dispute Resolution Association (NYSDRA), the Program Administrator.
NYSDRA will then notify you to forward it the required $120 filing fee. Upon receipt of
the filing fee, NYSDRA will begin processing your claim. If your form is rejected, it will
be returned to you with a statement indicating the reason for its rejection.

DO NOT SEND THE FILING FEE UNTIL YOU ARE NOTIFIED BY NYSDRA.

Please remember to sign and date the form. Failure to complete any question
or submit documents may result in a rejection of the form.
_____________________________________________________________________
NOTICE:
THE ARBITRATOR'S DECISION UNDER THIS PROGRAM IS BINDING ON BOTH
PARTIES, SUBJECT TO A LIMITED RIGHT OF APPEAL TO COURT BY EITHER
PARTY. YOU MAY WISH TO CONSULT AN ATTORNEY BEFORE PARTICIPATING
IN THIS PROGRAM. PLEASE READ "NEW YORK'S USED CAR LEMON LAW: A
CONSUMER'S GUIDE" CAREFULLY BEFORE COMPLETING THIS FORM.
_____________________________________________________________________
 Office Use Only: Case No. ____________________
Referred to NYSDRA ______________
Filing Date ______________________
NEW YORK STATE ATTORNEY GENERAL’S OFFICE
ANDREW M. CUOMO, ATTORNEY GENERAL

NEW YORK USED CAR LEMON LAW ARBITRATION PROGRAM

REQUEST FOR ARBITRATION FORM

CONSUMER INFORMATION

1. Name: ____________________________________________________________

Address: ____________________________________________________________

City: _____________________________ State:__________ Zip:__________

Phone: Home (______)_____-___________ Work:(______)______-___________

DEALER INFORMATION

2. Name: ____________________________________________________________

Address: ____________________________________________________________

City: _____________________________State:___________ Zip:__________

Phone: (______) _____ - _____________ Fax: (______) _____ - _____________

USED VEHICLE INFORMATION (Attach a copy of your Bill of Sale or Lease)

3. Manufacturer: ____________________________________________________________
(GM, Ford, Chrysler, Toyota, etc.)
4. Year: _________ Make: ____________________ Model: ___________________
(ex. Chevrolet, Dodge) (ex. Cavalier, Caravan)
5. Vehicle Identification Number (VIN):_________________________________________

6. Date of delivery: _______________________ Mileage at Delivery: ________________

7. Did you purchase or lease your vehicle in New York?................. Yes[ ] No[ ]
[ ] I purchased my vehicle. [ ] I leased my vehicle.

8. Purchase Price: $ ________________________

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9. Is your vehicle primarily used for personal, family or household
purposes? ..................................................................... .. Yes[ ] No[ ]

10. Do you still own (or lease) your vehicle? ................................. Yes[ ] No[ ]

WARRANTY INFORMATION

11. Which warranty applies to you (choose only one of the following)?

(a) 90 days or 4,000 miles from the date of delivery,

whichever came first, if the vehicle was purchased or
leased with between 18,000 and 36,000 miles?.................. Yes[ ] No[ ]
or
(b) 60 days or 3,000 miles from the date of delivery,
whichever came first, if the vehicle was purchased or
leased with between 36,001 and 80,000 miles?................... Yes[ ] No[ ]
or
(c) 30 days or 1,000 miles from the date of delivery,
whichever came first, if the vehicle was purchased or
leased with between 80,001 and 100,000 miles? ................ Yes[ ] No[ ]

12. Did you receive a written warranty? (If yes, attach copy).............. Yes[ ] No[ ]

BANK OR FINANCING INSTITUTION:

13. Name: ____________________________________________________________

Address: ____________________________________________________________

City: ____________________________ State:____________ Zip: ______________

LEASING COMPANY:

14. Name: ________________________________________________________________

Address:________________________________________________________________

City: _________________ State:_____ Zip:_______ Lease Acct#:____________

15. Total amount paid to date on lease (monthly payment x number of months, plus down
payment):................................................... $______________________

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VEHICLE'S PROBLEM(S)

16. Briefly describe the problem for which you now seek relief:

________________________________________________________________________

________________________________________________________________________

17. On what date and at what mileage did you first report this problem to the dealer?
Date: ______________________ Mileage: _______________________

18. Does the problem substantially impair the value of the vehicle to you?
................................................................................. Yes [ ] No [ ]

BASIS FOR RELIEF SOUGHT

19. Repair Attempts

A. How many repair attempts for the same problem were made by the dealer, or
authorized by the dealer, within the warranty period that applies to your vehicle
(see question #11)? ____________________

B. Give the date, mileage and work order number for each of the repair attempts by
the dealer for the same problem.

Problem 1. (Specify) __________________________________________

Date Mileage Work Order #

(1) ______________ _______________ _________________

(2) ______________ _______________ _________________

(3) ______________ _______________ _________________

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 Problem 2. (Specify) _________________________________________

Date Mileage Work Order #

(1) ______________ _______________ _________________

(2) ______________ _______________ _________________

(3) ______________ _______________ _________________

C. Do you have copies of all relevant work orders?......... Yes[ ] No [ ]

(If yes, attach copies of them. Otherwise, once accepted into the Program, you
may request copies from the dealer, with the arbitrator's approval, by writing to the
Administrator pursuant to Regulation §300.9.)

D. Did the problem continue to exist at the end of the third repair attempt?
....................................................................... Yes[ ] No [ ]

20. Days Out of Service

A. How many days was your vehicle out of service due to repairs or malfunction
within the warranty period that applies to your vehicle (see question #11)?
_____________ days.

B. List the dates, mileage, and repair order numbers for those repairs, where available:

From:________ To:________ Days out:_____ Mileage:___________ Work Order #____________

From:________ To:________ Days out:_____ Mileage:___________ Work Order #____________

From:________ To:________ Days out:_____ Mileage:___________ Work Order #____________

C. Do you have copies of all relevant work orders?........ Yes[ ] No[ ]

(If yes, attach copies of them. Otherwise, once accepted into the Program, you
may request copies from the dealer, with the arbitrator's approval, by writing to the
Administrator pursuant to Regulation §300.9.)

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HEARING LOCATION

21. Please indicate where you want the arbitration hearing to be held:

[ ] Albany [ ] Hempstead [ ] Oneida

[ ] Amsterdam [ ] Highland [ ] Oneonta
[ ] Auburn [ ] Hudson [ ] Oswego
[ ] Batavia [ ] Ilion [ ] Penn Yan
[ ] Binghamton [ ] Ithaca [ ] Plattsburgh
[ ] Bronx [ ] Jamaica [ ] Poughkeepsie
[ ] Brooklyn [ ] Jamestown [ ] Rochester
[ ] Buffalo [ ] Johnstown [ ] Saratoga Springs
[ ] Canandaigua [ ] Lake Placid [ ] Schenectady
[ ] Carmel [ ] Lower Manhattan [ ] Smithtown
[ ] Catskill [ ] Lowville [ ] Speculator
[ ] Cobleskill [ ] Lyons [ ] Staten Island
[ ] Corning [ ] Malone [ ] Syracuse
[ ] Cortland [ ] Monticello [ ] Troy
[ ] Delhi [ ] Montour Falls [ ] Upper Manhattan
[ ] Elmira [ ] New City [ ] Utica
[ ] Fort Edward [ ] Niagara Falls [ ] Waterloo
[ ] Geneseo [ ] Norwich [ ] Watertown
[ ] Glens Falls [ ] Ogdensburg [ ] Yonkers
[ ] Goshen [ ] Olean

TYPE OF HEARING AND RELIEF REQUESTED

22. [ ] Oral (In Person) [ ] Documents only (if dealer agrees)

PREVIOUS ARBITRATION

23. Did you participate in any previous arbitration for the

same problem(s) for which you now seek arbitration?............ Yes [ ] No [ ]

24. If yes, what was the name of the Program? _________________________________

25. Date of Decision: ________________________ (Attach copy of decision)

26. Did you accept the decision of the arbitrator? ..................... Yes [ ] No [ ]

27. Did the dealer comply with the decision?.............................. Yes [ ] No [ ]

SIGNATURE: ___________________________________ Date: _______________

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