Claim Form

CAMPAIGN NO.: 91V130

R/O CTL NO.:

DATE:


OWNER'S NAME: __________________________

ADDRESS: ________________________


CITY: ______________________________ STATE: __ ZIP:______-____

TELEPHONE: (___) ___-____


DEALER TEL. NO.: (___) ___-____ DEALER NAME: _____________________________


YEAR: __ MODEL: ___ VIN:_____________________ MILEAGE: __________


***** DO NOT SUBMIT THROUGH T.E.C. - MUST MAIL TO YUGO AMERICA, INC *****


ALL INFORMATION MUST BE FILLED IN TO RECEIVE WARRANTY REIMBURSEMENT


REPAIR COMPLETED: __/__/__ REPLACED ___ GROMETS PART NO. 2923


BY DEALER (CODE): __-____


OWNER'S SIGNATURE: ________________________________________________ DATE: __/__/__


DEALERSHIP'S SIGNATURE: ___________________________________________ DATE: __/__/__


NOTE

IF YOU ARE NOT THE PRESENT OWNER, PLEASE INDICATE VEHICLE STATUS:

__ TOTALED __STOLEN __ OTHER : _____________________________________


SOLD TO NAME: __________________________________________

ADDRESS:^?12G______________________________________________

CITY: _________________________________ STATE: __ ZIP: _____-____