Patrick Law Firm, P.C.- Potential Claim Questionaire

DEFECTIVE VEHICLE QUESTIONNAIRE

COMPLETE THIS FORM for an EXPERT CASE EVALUATION from a LICENSED ATTORNEY absolutely FREE.

If possible, please upload your REPAIR RECORDS where prompted below, or mail, fax,or e-mail your repair records to us. Repair records are helpful, but they are not essential for you to receive a free case evaluation. Please feel free to e-mail or call with any questions that you may have. We are CONSUMER ADVOCATES and will work diligently to PROTECT YOUR LEGAL RIGHTS and help you obtain just financial COMPENSATION.

QUESTIONS?

CALL TOLL-FREE

1-888-LEMON-81 or (214) 390-3343

Fax: (469) 914-6565

Date

Registered OwnerPlease Include Co-Purchaser if Applicable

Name

Street Address

City

State

Zip Code

Phone Number

E-mail Address

Fax Number

Name

Street Address

City

State

Zip Code

Phone Number

Dealer Information

Name:

City:

State

Vehicle Information

Year:

Make:

Model:

VIN #

Date Purchased:

Date

I purchased this vehicle:

I still own the vehicle:

Mileage at time of Purchase:

Current Mileage:

Purchase Price:

Repair History

How many times has your vehicle been repaired under warranty?

Has your vehicle been repaired three or more times for the same defect? If so, please describe:

Please estimate the total number of days your vehicle has been in the shop for repairs:

What defects does your vehicle currently have? Please Describe:

Click "Select File" to attach your Repair Records:

Select File

Additional comments and Information:

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Patrick Law Firm, P.C.

6244 E. Lovers Lane

Dallas, TX 75214

Call Toll Free: 1-888-LEMON-81 or (214) 390-3343

Email: craig@patricklaw.com

www.patricklaw.com