Super Duty Emissions Intake Form

Dear Super Duty Owner:

The below is a brief overview of information necessary to file a claim with our firm over the emissions scandal facing Ford. Rest assured we are asking each prospective owner for this info so if you have already provided it, this is not a case of us losing those details but, instead, for the ease of having all information necessary in one place.

If you have any questions, please do not hesitate to contact our offices. Once we receive your complete information, we will send out a representation agreement via Assure Sign to get your claim started!

Questions about the case? Click here for more information.

Name of Owner (Person on Title)*

First NameLast Name

Name of Second Owner (Second Person on Title - If Applicable)

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Primary Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Year of Vehicle*

Type of Vehicle*

Vehicle VIN Number*

Date of Purchase*

Date

Name of Dealership Where Vehicle Was Purchased*

State Vehicle Was Acquired*

Dealer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Purchase Price*

Bought or Leased?*

Still Own?*

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