MOTOR VEHICLE LEMON LAW NOTICE AND NONCONFORMITY REPORT
Wisconsin Department of Transportation
MV2691 5/20/2014
Demand for relief under Wis. Stat. s.218.0171
See Page 2 for Vehicle Defect and Repair Information
Pursuant to the Wisconsin Lemon Law, I am notifying the manufacturer identified below of the following: (check only one)
My vehicle has been made available for repair at least 4 times for the same defect during its first year under warranty.
My vehicle has been out of service at least 30 days because of one or more defects during its first year under warranty.
During the first year of use my warranty expired on: (m/d/yyyy) when the vehicle reached miles.
My vehicle was out of service at least 4 times or for 30 days because of one or more defects prior to that date.
Vehicle Identification Number (VIN)
Mileage of the Vehicle at the First Nonconformity
Purchase Price of the Motor Vehicle
Name of Selling or Leasing Dealer or Leasing Company
Address, City and State of Selling or Leasing Dealer or Leasing Company
Vehicle Delivery Date (m/d/yyyy)
Name of Financial Institution(s) that Financed or Leased Vehicle or that Have a Lien on Vehicle
My vehicle has a defect(s) that substantially impairs its use, value or safety. I demand that the manufacturer give me one of the following:
A comparable replacement vehicle and a refund of my collateral costs. (The manufacturer may, at its option, provide a complete
refund of the full purchase price paid for the vehicle, plus any sales tax, finance charge, amount paid by the consumer at the point
of sale and all collateral costs. This is to be provided within 45 days, except that 120 days shall be permitted for a vehicle having a
gross vehicle weight rating or actual weight in excess of 10,000 pounds.)
I purchased the vehicle and demand a refund of the full purchase price of the vehicle plus any sales tax, finance charge,
amount paid by me at the point of sale and collateral costs, less a reasonable amount for use, calculated in accordance with
Wis. Stat. ss.218.0171(2)(b)2.
I leased the vehicle and demand a refund for the current value of the written lease be given to the motor vehicle lessor and to
any holder of a perfected security interest in the vehicle, and a refund to me, the consumer, of all amounts I paid under the
written lease plus any sales tax and collateral costs, less a reasonable allowance for use, calculated in accordance with
Wis. Stat. ss.218.0171(2)(b)3.
Itemization of collateral costs and any other damages I have incurred in connection with vehicle repairs. (Examples include alternative
transportation, rental care fees and towing costs. Attach additional pages if needed.) Describe:
Description of non-removable options that have been added to my vehicle after the sale, but not included in the vehicle purchase price.
(Examples include sunroof, rustproofing, roof rack, pinstriping, etc. Attach additional pages if needed.) Describe:
Description of missing equipment or serious unrepaired vehicle damage. (Do not include normal wear and tear such as minor dents,
scratches, pitted glass, soiled carpets, minor stains or tears. Attach additional pages if needed.) Describe:
I offer to return my motor vehicle and transfer title after the manufacturer meets my demand for Lemon Law relief. I hereby authorize the
manufacturer to contact the financial institution(s) identified above for financing information needed to calculate a refund. Authorization
expires 35 days from the date this document is executed. (see below).
NOTICE FOR OWNERS OF A VEHICLE WITH A GROSS VEHICLE WEIGHT RATING OR ACTUAL WEIGHT IN EXCESS OF 10,000
POUNDS: If you, as a heavy vehicle owner, enter into any negotiated written settlement with the manufacturer, you thereby waive all of
your rights under the Wisconsin Lemon Law, Wis. Stat. s. 218.0171.
Owner Name (First, MI, Last – Print)
Home (Area Code) Telephone Number (optional)
Co-Owner Name (First, MI, Last – Print) (if any)
Work (Area Code) Telephone Number (optional)
Address, City, State, ZIP Code
FAX (Area Code) Telephone Number (optional)
(Owner Signature) (Date – m/d/yyyy)
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signature
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