Claim Form

CLAIM FORM

Claimant (Consumer) Information

First Name

Last Name

Please check if a non-U.S. address

Current Address

Current Address Continued

City

State

Zip Code

Province

Postal Code

Country

Email Address

Daytime Phone

Evening Phone

Vehicle Information

Make

Model

License Plate Number

Vehicle Identification Number (VIN)

Was this vehicle used or intended to be used for commercial purposes?

Yes

Dealer Who Is The Subject Of Your Claim

Dealer's Trade Name

Dealer's Address

City

State

Zip

Telephone Number

To your knowledge, is the dealer still in business?

Yes

Explain

Claim Information

Dealer Failed To		You Must Provide
Transfer License or Registration Fees to DMV		• A copy of your contract with the dealer
Pay the Proceeds of a Consignment Sale		• A copy of consignment agreement • Document(s) showing sale of consigned vehicle
Pay Off the Remaining Lien Amount on your Trade-In Vehicle		• A billing statement, or other documents from your lender, showing the amount due • A copy of your contract with the dealer
Provide Good Title		• A copy of your contract with the dealer • A billing statement, or other documents from the legal owner or other claimant (consumer) of amount claimed to be owed and the amount, if any, that he or she received from the dealer or lessor-retailer
Pay Third Parties for Insurance, Service Contract, or Goods or Services		• A copy of your contract with the dealer • A billing statement, or other documents from the third party of the amount, if any, that he or she received from the dealer or lessor-retailer

Amount Claimed

Date Of Incident

Describe the events on which you base this claim

Why did you claim the amount you did?

Amount

Reason

Have you taken any action to recover all or part of the claim, such as making a claim under the dealer's bond or suing in Small Claims Court?

Yes

Amount Claimed

Please explain the result and current status

Have any payments been made toward the balance owed on your trade-in since the contract was signed?

Yes

Payor 1

Date Paid

Amount Paid

Payor 2

Date Paid

Amount Paid

Payor 3

Date Paid

Amount Paid

Payor 4

Date Paid

Amount Paid

Payor 5

Date Paid

Amount Paid

Payor 6

Date Paid

Amount Paid

Required Documentation

Please include the requested documents related to the type of claim you are filing. Be advised that the CMVRC may require reasonable additional information to process eligible claims.

IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO TRANSFER LICENSE OR REGISTRATION FEES, PLEASE PROVIDE:
- A copy of your agreement or contract with the Dealer/Lessor-Retailer
IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PAY THE PROCEEDS OF A CONSIGNMENT SALE, PLEASE PROVIDE:
- A copy of your agreement or contract with the Dealer/Lessor-Retailer
- All documents showing sale of consigned vehicle
IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PAY THE BALANCE OWING ON YOUR TRADE-IN VEHICLE, PLEASE PROVIDE
- A copy of your agreement or contract with the Dealer/Lessor-Retailer
- A billing statement, or other document from your lender, showing the amount due
IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PROVIDE GOOD TITLE, PLEASE PROVIDE:
- A copy of your agreement or contract with the Dealer/Lessor-Retailer
- A billing statement, or other documents from the legal owner, such as a bank or finance company, or other claimant (consumer) of the amount that is claimed to be owed and the amount, if any, that he or she received from the dealer or lessor-retailer.
IF YOU ARE CLAIMING THAT A DEALER/LESSOR-RETAILER FAILED TO PAY THIRD PARTIES FOR INSURANCE, SERVICE CONTRACTS, OR GOODS OR SERVICES PURCHASED THROUGH THE DEALER, PLEASE PROVIDE:
- A copy of your agreement or contract with the Dealer/Lessor-Retailer
- A billing statement, or other documents from the third party of the amount, if any, that he or she received from the dealer or lessor-retailer

Click the "Browse" or “Choose File” button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only.

You may upload up to 10 files.

Total upload size can not be larger than 10 MB.

If there are problems uploading, please inquire via mail or email.
P.O. Box 8060
San Rafael, CA 94901-8060
info@vehiclerecoveryfund.org

Your Obligation To Update Information And Authorization For CMVRC To Obtain Information

You must notify the CMVRC of any changes or updates to the information contained in your claim form, including notice of any payments you have received from your insurance company, the dealer, the dealer’s bond, or any other person or entity. If you fail to notify the CMVRC of any changes or updates, the CMVRC may deny your claim. You agree to repay to the CMVRC to the extent you receive any money from anyone for the loss covered by CMVRC’s payment to you.

The CMVRC may contact the Dealer/Lessor-Retailer, the Department of Motor Vehicles, a financial institution or others to get information about your claim.

By submitting this Claim Form, you authorize the CMVRC to request and obtain information to determine whether your claim is eligible for payment. You authorize the Dealer/Lessor-Retailer that is the subject of this claim, the Department of Motor Vehicles, lessors, financial institutions, and other persons to cooperate with the CMVRC and to release to the CMVRC any record(s) or other information that the CMVRC in its discretion may request to determine whether your claim is eligible for payment.

Certification I declare under penalty of perjury under the laws of the State of California that the information provided in this claim and accompanying documents is true and correct.

By submitting this claim, you acknowledge that you hold the [Settlement Administrator/Claims Administrator (as defined in court docs)] harmless from any and all losses, claims, liabilities, damages, or suits arising out of or in connection with the issuance of any distribution payment in this matter, including those resulting from the submission of incorrect contact information or fraud.

Your typed name will serve as your electronic signature

Required

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