AMERICAN ARBITRATION ASSOCIATION SUPPLEMENTARY PROCEDURES FOR CONSUMER-RELATED DISPUTES How to file a claim; businesses should: How to file a claim; consumers should: • Fill out this form and retain one copy for your records. • Mail two copies of this form and your check or money order made payable to the AAA, to the AAA Case Management Center nearest to you. Please consult Section C-8 of the Supplementary Procedures for ConsumerRelated Disputes for the appropriate fee. • Send a copy of this form to the consumer by registered mail return receipt requested. • Fill out this form and retain one copy for your records. • Mail two copies of this form and your check or money order made payable to the AAA, to the AAA Case Management Center nearest to you. Please consult Section C-8 of the Supplementary Procedures for ConsumerRelated Disputes for the appropriate fee. • Send a copy of this form to the business. 1 How is this claim being filed? Check only one. [ ] By request of the consumer (A copy of the arbitration agreement must be attached. A copy of this form must also be sent to the business) [ ] By request of the business (A copy of the arbitration agreement must be attached. A copy of this form must also be sent to the consumer by registered mail return receipt requested) -or[ ] By mutual agreement (“submission”) of the parties (both parties must sign this form) 2 Briefly explain the dispute. 3 Do you believe there is any money owed to you? If yes, how much? 4 Is there any other outcome you want? If yes, what is it? 5 Preferred hearing locale (if an in-person hearing is held) ______________________________________________ 6 Fill in the following information [ ] Yes [ ] No Consumer Business Name of Consumer ______________________________ Name of Business ___________________________ Address _______________________________________ Address ___________________________________ City/State/Zip___________________________________ City/State/Zip_______________________________ Telephone _____________________________________ Telephone _________________________________ Fax ___________________________________________ Fax _______________________________________ Signature of Consumer ___________________________ Signature of Business ________________________ Representative __________________________________ Representative _____________________________ Firm __________________________________________ Firm _____________________________________ Address _______________________________________ Address ___________________________________ City/State/Zip___________________________________ City/State/Zip_______________________________ Telephone _____________________________________ Telephone _________________________________ Fax ___________________________________________ Fax _______________________________________ AAA Customer Service 1-800-778-7879 AAA Web site: www.adr.org American LegalNet, Inc. www.FormsWorkflow.com