Consumer Mediation Services - Mediation Request Form

Contact Information

Please enter your contact information. Fields with '*' are required entries.

First Name:

MI:

Last Name:

Address:

City:

State:

Zip Code:

Telephone:

( ) -

How did you hear about us?

Email:

Confirm Email:

Vehicle Information

Please enter information about your vehicle.

Make:

Model:

Year:

Current Mileage:

Purchase/Lease Information

Date of Purchase/Lease:

Purchase or Lease:

Purchase

Lease

Mileage at Purchase/Lease:

Vehicle Condition:

New

Used

Type of Warranty on Vehicle:

Manufacturer

Extended

None

Involved Parties

Selling Dealer

Dealer Name:

Dealer Address:

City:

State:

Zip Code:

Telephone:

( ) -

Servicing Dealer

Same as Selling Dealer

Dealer Name:

Address:

City:

State:

Zip Code:

Telephone:

( ) -

Written Notice

Have you given written notice of defects to manufacturer?

Yes

Has manufacturer (or designated agent) attempted repairs?

Yes

Complaint Details

Please use the field below to enter details about your complaint:

What are you seeking as a resolution to your complaint?

Review Your Information

Personal Information

Name:

Address:

City:

State:

Zip Code:

Phone:

Email:

Vehicle Information

Make:

Model:

Year:

Current Mileage:

Purchase Date:

Purchase Type:

Vehicle Condition:

Purchase Mileage:

Warranty Type:

Dealer Information

Selling Dealer

Name:

Address:

City:

State:

Zip Code:

Phone:

Service Dealer

Name:

Address:

City:

State:

Zip Code:

Phone:

Written Information

Complaint Details:

Expected Resolution:

How you heard about us:

IMPORTANT NOTICE:

I voluntarily consent to the New Motor Vehicle Board's release of personal information contained in this form to the dealer(s), manufacturer, distributor, or other parties named herein for the purposes of mediating this dispute and until such time as the complaint is resolved or I withdraw my consent.

Section 20 and 3000 of the California Vehicle Code make it unlawful to use a false or fictitious name or knowingly make false statements or knowingly conceal any material fact in any document filed with the New Motor Vehicle Board.

Click "Submit" to complete your request. A copy of your completed form will be sent to the email address provided. Click "Back" to go back to previous steps to make edits.