AA-71 (2/15)
Franchised Motor Vehicle Dealer
REQUEST FOR ADJUDICATORY PROCEEDING
Division of Safety & Business Hearings
Telephone: (518) 474-1509
Fax: (518) 473-8505
INSTRUCTIONS FOR REQUEST
1) All documents relevant to the claim(s) made in this request, including all correspondence between the dealer and franchisor,
must accompany this request when it is filed with the Commissioner. Include a copy of the current franchise agreement that
exists between the dealer and the franchisor, and a copy of the certificate of service (see Instruction #2). Submit to:
NYS Department of Motor Vehicles
Div. Safety and Business Hearings, Room 424A
6 Empire State Plaza
Albany, NY 12228
2) At the time this request is filed with the Commissioner, a true copy of this request, with copies of all documents filed with it,
must be served upon the franchisor in any manner specifically permitted under the terms of the franchise agreement or, if no
such manner is specified, then via certified mail, return receipt requested, addressed to the officer or employee of the
franchisor from whom the dealer has received correspondence relevant to the claims made in this request.
3) This request must be accompanied by a non-refundable filing fee of two thousand dollars ($2,000). Attach a certified check or
money order payable to the Commissioner of Motor Vehicles.
4) In a short, plain statement present the facts that support your claim that the franchisor has violated one or more specific provisions
of Article 17-A Franchised Motor Vehicle Dealer Act. Also, describe your request for a specific remedy other than damages.
(Use additional sheets as necessary.)
Date
Please Sign Here
x
Name: AKA/DBA
Address
(include number & Street)
City State Zip Code Telephone # ____________________
Dealer Certificate of Registration No.: Represented by:
Franchisor
Address
(include number & Street)
City State Zip Code Telephone #
Represented by (if known):
Address
(include number & Street)
City State Zip Code Telephone #
Requests a New York State Department of Motor Vehicles Adjudicatory proceeding with:
COMPLETE THE INFORMATION REQUESTED BELOW. PLEASE PRINT.
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Your attention is directed to the automatic stay provisions, without bond, under Vehicle and Traffic Law Sections 463(2)(e)(1) and 465(7).
