Nj Lemon Law Application – Fill Out and Use

New Jersey Ofice of the Attorney General

Division of Consumer Affairs

Ofice 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:___________________________________________		For oFFice Use only
	address: ________________________________________
	City:____________________________________________		L.L. case number:_____________________________
	state: ________________________ ZiP: _____________		Assigned to:_____________________________
	Home telePHoNe Number: ___________________________		Date accepted:_____________________________
	(iNClude area Code)
	Work telePHoNe Number:___________________________	O.A.L. docket number:___________________________
	(iNClude area Code)
	FaX telePHoNe Number:____________________________		Date completed:_____________________________
	(iNClude area Code)
	e-mail address: __________________________________		Approved by:_____________________________
	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 irm:________________________________________________________________________________________________

Address: ________________________________________________________________________________________________

City:__________________________________________________State: ________________________ZIP code:_____________

Telephone number: ______________________________________FAX number: ______________________________________

(include area code)	(include area code)
e-mail address: ________________________________________

2.Manufacturer: __________________________________________________________________________________________

Make: _____________________________________________		Model: __________________________________________
Year:_________________	Color:____________________	Body type: _______________________________________

4. What was the mileage on delivery? ______________________

Present mileage: _____________________

5.Date of delivery: ____________________________________

Month

Day

Year

6.The vehicle identiication 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 modiications.

Please specify and attach receipts _________________________________________________________ .

Nonconformity Repair Information

11.Briely 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 modiication or alteration?	Yes	No
	If “Yes,” please explain: ___________________________________________________________________________________
	_______________________________________________________________________________________________________
13.	Have you notiied the manufacturer of the defect, by certiied mail, return receipt requested?	Yes	No
	What was the certiied mail return receipt date? _______________ What was the vehicle’s mileage at the time? _____________
14.	Was there a inal repair attempt?	Yes	No
	If “Yes,” what was the date of the inal repair attempt? _____________________________________
	What was the vehicle’s mileage at the time of the inal 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 irst presented your vehicle to the dealer for repair of the defect?_________________________________

What was the vehicle’s mileage at the time? _________________________________