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Fillable Printable Form VS-35 - Vehicle Safety Complaint Report - New York

Fillable Printable Form VS-35 - Vehicle Safety Complaint Report - New York

Form VS-35 - Vehicle Safety Complaint Report - New York

Form VS-35 - Vehicle Safety Complaint Report - New York

FOR OFFICE USE ONLY
Facility
Number
C.O. Case
Number
CSR
Region
R.O. Case
Number
Your
Name
Name of
Facility
Address - Number
and Street
Address - Number
and Street
CityStateZip CodeCityStateZip Code
Telephone Number (Include area code)
Home ( ) Work ( )
Telephone Number
(Include area code) ( )
Vehicle Identification
Number
Identification Number
of Facility
Vehicle Year, Make, ModelPlate
Number
CylindersName of Person with whom
you dealt at facility
Date of repair/inspection/purchaseOdometer reading at time of repair/
inspection/purchase
Today’s
Date
Current odometer reading at time
of filing the complaint
County
New York State Department of Motor Vehicles
Division of Vehicle Safety
COMPLAINT REPORT
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.
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
ANSWER QUESTIONS BELOW AND/OR ON PAGE 2 OF THIS FORM THAT APPLYTO 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? Yes No
If Yes, do you have the replaced parts?
Yes No
5. Did you authorize any additional repairs? Yes No Specify______________________________________________________
6. Were you charged for work not performed? Yes 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 # _________________________ Expiration Date _________________________
6. Did you receive an inspection receipt?
Yes No If yes, attach a copy of the receipt.
VS-35 (3/11)
PAGE 1 OF 2
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/ /
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?
Yes No If No, would you go back if the dealer offered to make
repairs or adjustments?
Yes No
3. Was a Temporary Certificate of Registration issued?
Yes No If yes, what is the facility number written on the temporary
registration? ___________________________
4. Inspection Certificate # _________________________ Expiration Date _________________________
NOTE: If a repair or diagnosis of the vehicle was made, complete Section Aon 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 2700-
ESP, 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.
VS-35 (3/11)
www.dmv.ny.gov
PAGE 2 OF 2
±
________________________________________________ _______________________
(Signature) (Date)
/ /
reset/clear
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