VS-35 (3/11) New York State Department of Motor Vehicles Division of Vehicle Safety FOR OFFICE USE ONLY Facility Number COMPLAINT REPORT C.O. Case Number INSTRUCTIONS: (Before filing your complaint, please attempt to settle this matter with the facility.) Check the appropriate box to show the type of complaint involved. CSR Vehicle repair Vehicle inspection Vehicle purchase We can only accept complaints about repairs up to 90 days or 3,000 miles (whichever comes first) after the date repairs were completed. The only exception is a written warranty that may exceed these time and/or mileage limits. PLEASE PRINT OR TYPE ALL ENTRIES AND USE BLACK INK Your Name R.O. Case Number Name of Facility Address - Number and Street County Region Address - Number and Street City State Zip Code Telephone Number (Include area code) Home ( ) Work ( City Telephone Number (Include area code) ( ) Vehicle Identification Number Vehicle Year, Make, Model Date of repair/inspection/purchase / / State Zip Code ) Identification Number of Facility Plate Number Cylinders Odometer reading at time of repair/ inspection/purchase Name of Person with whom you dealt at facility Today’s Date / Current odometer reading at time of filing the complaint / ANSWER QUESTIONS BELOW AND/OR ON PAGE 2 OF THIS FORM THAT APPLY TO YOUR COMPLAINT A. Repair Complaint 1. Describe the specific reason you brought the vehicle to the repair shop: ____________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Did you ask for a written estimate of the parts and labor necessary to do the repair? Yes No If Yes, attach a copy of the estimate. 3. What was the actual cost of repair? $____________________ (Attach invoice) 4. Before the repair was performed, did you ask that any replaced part be returned to you? If Yes, do you have the replaced parts? Yes No 5. Did you authorize any additional repairs? Yes 6. Were you charged for work not performed? No Yes Yes No Specify ______________________________________________________ No Explain ____________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. Was any unnecessary or unauthorized work performed? Yes No Specify __________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. Did you go to another facility to have the problem corrected? Yes* No * If Yes, attach invoice and give us the following information about the facility: Name _____________________________________________________________ Facility ID No. ______________________________ Street ________________________________________________________________________________________________________ City __________________________ State __________ Zip Code _____________ Telephone No. ( ) ______________________ B. Inspection Complaint 1. Did the inspection station refuse to inspect your vehicle? Yes No 2. Did the inspection station refuse to give you an appointment date in writing? Yes No 3. Were you told or led to believe that repairs necessary to pass inspection had to be made at the same station? Yes No 4. How much were you charged for the inspection $___________________. 5. Inspection Certificate # _________________________ 6. Did you receive an inspection receipt? Yes No / / Expiration Date _________________________ If yes, attach a copy of the receipt. PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com C. Vehicle Purchase Complaint Attach a copy of your Bill of Sale and/or Certificate of Sale. 1. Were any vehicle components in need of repair or adjustment? Yes No If Yes, which components? ____________________ ____________________________________________________________________________________________________________ 2. Have you gone back to the dealer for repairs or adjustments? repairs or adjustments? Yes No 3. Was a Temporary Certificate of Registration issued? Yes registration? ___________________________ 4. Inspection Certificate # _________________________ Yes No No If No, would you go back if the dealer offered to make If yes, what is the facility number written on the temporary Expiration Date _________________________ / / NOTE: If a repair or diagnosis of the vehicle was made, complete Section A on the front of this form. D. If there is additional information that will help us to evaluate your complaint, please include this information below or use an additional sheet of paper.. E. What do you want done to resolve this complaint to your satisfaction? Are you willing to appear and testify at a hearing if one is held to resolve this complaint? Yes No Be sure to attach COPIES of any supporting correspondence and/or documents such as receipts, invoices, written estimates, written guarantees or warranties, cancelled checks or credit card transaction forms. Sign below and mail this complaint form with all necessary attachments to: BUREAU OF CONSUMER & FACILITY SERVICES, PO BOX 2700ESP, ALBANY NY 12220-0700. Phone #: (518) 474-8943 Fax:(518) 486-4102 I understand that a copy of this form and any or all of the enclosed information may be sent to the facility shown on the front of this form. All information provided in this complaint is true and factual. ± ________________________________________________ (Signature) VS-35 (3/11) _______________________ (Date) www.dmv.ny.gov PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com