Wisconsin Department of Transportation
MV2692 5/2014 Wis. Stat. s.218.0171(2)(a) Notice
Please repair the following under the original manufacturer’s warranty for my vehicle (describe repair needed):
Vehicle Make
Vehicle Model
Vehicle Year
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
Itemization of Damages Claimed by Consumer
None See Attached Itemization
Address, City and State of Selling or Leasing Dealer or Leasing Company
Name of Financial Institution(s) that Financed or Leased Vehicle or that Have a Lien on Vehicle
Loan Account Number(s) (optional)
Consumers: Keep a copy of this form MV2692 Vehicle Warranty Repair Request / Nonconformity Report for your records.
You may be asked or requested to show this document if the vehicle is not satisfactorily repaired and you wish to request a
replacement vehicle or a refund under state law.
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)
Email Address
FAX (Area Code) Telephone Number (optional)
Address, City, State, ZIP Code
(Acknowledgement of Receipt by (Date m/d/yyyy)
Dealer / Manufacturer Signature)
(Owners Signature) (Date m/d/yyyy)
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