Fillable Instructions for Completing the Application for New Car (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Instructions for Completing the Application for New Car (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Ofce of Consumer Protection
Lemon Law Unit
P.O. Box 45026
Newark, New Jersey 07101
(973) 504-6226
(800) 242-5846
E-Mail: lemonlaw@dca.lps.state.nj.us
WEbsitE: www.state.nj.us/lps/ca/home.htm
Instructions for Completing the Application
for New Car Lemon Law Dispute Resolution
Please complete the attached application either by typing or printing legibly in dark ink. Be accurate
and thorough. You must attach a clear copy of all relevant documents, including the sales contract or lease
agreement, service or work orders and correspondence between you and the manufacturer, or its authorized
dealer, relating to the problem(s). Do not send your original documents.
Sign and return the completed application, together with a copy of each document, to the New Jersey
Division of Consumer Affairs, Lemon Law Unit, P.O. Box 45026, Newark, NJ 07101.
The Lemon Law Unit will review your application for completeness and eligibility. If the application
is accepted, you will be notied and asked (only after acceptance) to forward a ling fee of $50. Do not
send the ling fee until you are notied to do so. If your application is rejected, it will be returned to you
with a statement of the reason(s) for its rejection.
Please remember to sign and date the application. Your failure to complete any questions or submit all
of the required documents may result in the rejection of your application.
Notice
The decision of the Director of the Division of Consumer Affairs under this program is binding on both
parties, subject to a right of appeal to the Superior Court by either party. You may wish to consult an attorney
before participating in this program, since the manufacturer will be represented by an attorney.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Ofce of Consumer Protection
Lemon Law Unit
P.O. Box 45026
Newark, New Jersey 07101
(973) 504-6226
(800) 242-5846
E-Mail: lemonlaw@dca.lps.state.nj.us
New Car Lemon Law Dispute Resolution Application
Please be advised that any information you supply on this complaint form may be subject to public disclosure. If an investigation into the
matter is conducted, the information is subject to public disclosure only after the completion of the investigation. You are also advised
that the completed complaint form is a “government record,” which the Lemon Law Unit may be obligated to provide to anyone making
a request pursuant to the Open Public Records Act (OPRA).
Consumer Information
Name:___________________________________________
address: ________________________________________
City:____________________________________________
state:________________________ ZiP:_____________
HometelePHoNeNumber:___________________________
(iNCludeareaCode)
WorktelePHoNeNumber:___________________________
(iNCludeareaCode)
FaXtelePHoNeNumber:____________________________
(iNCludeareaCode)
e-mailaddress:__________________________________
For statistical and informational purposes only. Your age: 18-29 30-44 45-59 60 or older
Attorney Information (If an attorney is going to represent you, please provide the following information.)
Attorney’s name: __________________________________________________________________________________________
Law rm: ________________________________________________________________________________________________
Address: ________________________________________________________________________________________________
City:__________________________________________________State: ________________________ZIP code: _____________
Telephone number: ______________________________________FAX number: ______________________________________
(include area code) (include area code)
e-mailaddress:________________________________________
Vehicle Information
1. Is the vehicle registered in New Jersey? Yes No
If “No,” was the vehicle purchased or leased in New Jersey? Yes No
2. Manufacturer: __________________________________________________________________________________________
Make: _____________________________________________ Model: __________________________________________
Year: _________________ Color:____________________ Body type: _______________________________________
3. Is your vehicle normally used for commercial purposes? Yes No
For oFFice Use only
L.L. case number:_____________________________
Assigned to:_____________________________
Date accepted:_____________________________
O.A.L. docket number: ___________________________
Date completed:_____________________________
Approved by:_____________________________
4. What was the mileage on delivery? ______________________ Present mileage: _____________________
5. Date of delivery:
____________________________________
Month Day Year
6. The vehicle identication number (the VIN can be found on the registration): _________________________________________
7. Dealer from which the vehicle was purchased or leased:
Name: ____________________________________________________ Telephone number : _____________________________
(include area code)
Street Address: ___________________________________________________________________________________________
City: ______________________________________ State: ______________________________ ZIP code: _______________
8. Company to which you make monthly payments:
Name: ____________________________________________________ Telephone number : _____________________________
(include area code)
Street Address: ___________________________________________________________________________________________
City: ______________________________________ State: _______________________________ ZIP code: _______________
Please provide the loan or lease account number: ________________________________________________________________
Financial Information
9. Please attach a copy of all sales or lease documents and receipts.
10. Other costs, including: any towing charges, rental fees and/or cost of modications.
Please specify and attach receipts _________________________________________________________ .
Nonconformity Repair Information
11. Briey describe the defect which substantially impairs your vehicle’s use, value or safety.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
12. Is this defect the result of your abuse, neglect or an unauthorized modication or alteration? Yes No
If “Yes,” please explain: ___________________________________________________________________________________
_______________________________________________________________________________________________________
13. Have you notied the manufacturer of the defect, by certied mail , return receipt requested? Yes No
What was the certied mail return receipt date? _______________ What was the vehicle’s mileage at the time? _____________
14. Was there a nal repair attempt?
Yes No
If “Yes,” what was the date of the nal repair attempt? _____________________________________
What was the vehicle’s mileage at the time of the nal repair attempt? __________________________
If “No,” please explain: ____________________________________________________________________________________
_______________________________________________________________________________________________________
15. Was the vehicle ever repaired by anyone other than a dealer authorized by the manufacturer? Yes No
If “Yes,” by whom? _______________________________________________________________________________________
16. If you answered “Yes” to question number 15, was that repair authorized by the manufacturer or its dealer?
Yes No
17. What was the date you rst presented your vehicle to the dealer for repair of the defect?
_________________________________
What was the vehicle’s mileage at the time? _________________________________
18. If your vehicle experienced one or more defects, was the car out of service due to repairs for a total of 20 or more days?
If “Yes,” how many days? __________________ Yes No
19. Give a chronology of the repair attempts for the defect.
Brief description of problem(s)
1
st
Defect Date Mileage Days out of service
__________________________________________________ _______________ _________________ _________
__________________________________________________ _______________ _________________ _________
__________________________________________________ _______________ _________________ _________
__________________________________________________
2
nd
Defect Date Mileage Days out of service
__________________________________________________ _______________ _________________ _________
__________________________________________________ _______________ _________________ _________
__________________________________________________ _______________ _________________ _________
__________________________________________________
20. Do any of the problems continue to exist? Yes No
If “Yes,” please explain: ___________________________________________________________________________________
_______________________________________________________________________________________________________
21. Please check one:
The defect substantially impairs the use, value or safety of the vehicle.
The defect is a “serious safety defect” which is likely to cause death or serious bodily injury if the vehicle is driven.
Additional Information
22. Have you previously participated in any arbitration for the nonconformity for which you are now seeking relief?
Yes No
If “Yes,” what was the date of the nal arbitration decision? __________________________________
Did you accept the decision? Yes No
If “Yes,” please explain and give the current status:
(Use additional sheets of paper if needed.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I certify that the manufacturer has not yet given me a refund or replacement, and that all statements made in connection with
this request for dispute resolution are true to the best of my knowledge. I understand that this document and its attachments are a
part of the public record.
I am aware that I can participate in the dispute resolution process regarding this motor vehicle only once and that further
applications will not be accepted after a nal decision is issued in this case.
_____________________________________________________ ____________________________
Signature Date
If you have not already done so, please attach a copy (do not send the original) of the following documents:
• Final repair opportunity letter to the manufacturer • Purchase order
• Certied mail return receipts • Finance agreement
• All relevant evidence of repair attempts • Lease agreement
• Sales invoice • Work orders/repair invoices
• All towing charges, rental fees, expert witness fees and legal fees • Vehicle registration
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Instructions for Completing the Application for New Car (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 21 July 2020

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