| How many times has the dealer tried to fix your car: |
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| Basic description of defects/symptoms you are experiencing with your lemon vehicle: |
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| Current odometer reading: |
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| Year, make and model of your lemon vehicle: |
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| First Name: |
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| Last Name: |
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| Address 1: |
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| Address 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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