Form CFB009 "New York Wheelchair Lemon Law Arbitration Program Request for Arbitration Form" - New York

What Is Form CFB009?

This is a legal form that was released by the New York State Attorney General - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2019;
  • The latest edition provided by the New York State Attorney General;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CFB009 by clicking the link below or browse more documents and templates provided by the New York State Attorney General.

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Download Form CFB009 "New York Wheelchair Lemon Law Arbitration Program Request for Arbitration Form" - New York

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INSTRUCTIONS FOR COMPLETING
THE WHEELCHAIR LEMON LAW
REQUEST FOR ARBITRATION FORM
To participate in the New York State Wheelchair Lemon Law
Arbitration Program, you must complete the attached form. Be as
accurate and complete as possible. You may send this form
electronically or by regular mail. Please attach copies of all
relevant documents (including your purchase or lease agreement, all service or work orders relating
to the problem for which you seek this arbitration, and any correspondence between you and the
manufacturer or its authorized dealer relating to such problem). DO NOT SEND ORIGINAL
DOCUMENTS. Sign and return the completed form, together with your documents, to:
New York State Attorney General's Office
28 Liberty Street, 15
Floor
th
New York, NY 10005
Attention: WHEELCHAIR LEMON LAW ARBITRATION UNIT.
Or Email to: NYAG.LemonLaw@ag.ny.gov
The Attorney General's Office will review your form and advise you whether your claim is accepted
in the arbitration program. If the form is accepted, you will be notified by the Attorney General's
Office which will then forward your form and documents to the New York State Dispute
Resolution Association (NYSDRA), the Program Administrator. NYSDRA will then notify you to
send it the required $100 filing fee. Upon receipt of the filing fee, NYSDRA will begin processing
your claim. If your form is rejected by the Attorney General=s Office, it will be returned to you with
a statement indicating the reason for its rejection.
DO NOT SEND FILING FEE UNTIL YOU ARE REQUESTED TO BY NYSDRA.
Please remember to sign and date the form. Failure to complete any question or submit
documents may result in a rejection of the form.
________________________________________________________________________
NOTICE:
THE ARBITRATOR'S DECISION UNDER THIS PROGRAM IS BINDING ON BOTH PARTIES,
SUBJECT TO A LIMITED RIGHT OF APPEAL TO COURT BY EITHER PARTY. YOU MAY
WISH TO CONSULT AN ATTORNEY BEFORE PARTICIPATING IN THIS PROGRAM.
PLEASE READ "NEW YORK'S WHEELCHAIR LEMON LAW: A GUIDE FOR CONSUMERS"
CAREFULLY BEFORE COMPLETING THIS FORM.
________________________________________________________________________
INSTRUCTIONS FOR COMPLETING
THE WHEELCHAIR LEMON LAW
REQUEST FOR ARBITRATION FORM
To participate in the New York State Wheelchair Lemon Law
Arbitration Program, you must complete the attached form. Be as
accurate and complete as possible. You may send this form
electronically or by regular mail. Please attach copies of all
relevant documents (including your purchase or lease agreement, all service or work orders relating
to the problem for which you seek this arbitration, and any correspondence between you and the
manufacturer or its authorized dealer relating to such problem). DO NOT SEND ORIGINAL
DOCUMENTS. Sign and return the completed form, together with your documents, to:
New York State Attorney General's Office
28 Liberty Street, 15
Floor
th
New York, NY 10005
Attention: WHEELCHAIR LEMON LAW ARBITRATION UNIT.
Or Email to: NYAG.LemonLaw@ag.ny.gov
The Attorney General's Office will review your form and advise you whether your claim is accepted
in the arbitration program. If the form is accepted, you will be notified by the Attorney General's
Office which will then forward your form and documents to the New York State Dispute
Resolution Association (NYSDRA), the Program Administrator. NYSDRA will then notify you to
send it the required $100 filing fee. Upon receipt of the filing fee, NYSDRA will begin processing
your claim. If your form is rejected by the Attorney General=s Office, it will be returned to you with
a statement indicating the reason for its rejection.
DO NOT SEND FILING FEE UNTIL YOU ARE REQUESTED TO BY NYSDRA.
Please remember to sign and date the form. Failure to complete any question or submit
documents may result in a rejection of the form.
________________________________________________________________________
NOTICE:
THE ARBITRATOR'S DECISION UNDER THIS PROGRAM IS BINDING ON BOTH PARTIES,
SUBJECT TO A LIMITED RIGHT OF APPEAL TO COURT BY EITHER PARTY. YOU MAY
WISH TO CONSULT AN ATTORNEY BEFORE PARTICIPATING IN THIS PROGRAM.
PLEASE READ "NEW YORK'S WHEELCHAIR LEMON LAW: A GUIDE FOR CONSUMERS"
CAREFULLY BEFORE COMPLETING THIS FORM.
________________________________________________________________________
Office Use Only:
Case No.
_________________________
Referred To NYSDRA __________________
Filing Date
_________________________
NEW YORK STATE ATTORNEY GENERAL=S OFFICE
LETITIA JAMES, ATTORNEY GENERAL
NEW YORK WHEELCHAIR LEMON LAW ARBITRATION PROGRAM
REQUEST FOR ARBITRATION FORM
CONSUMER INFORMATION
1.
Name:
______________________________________________________________________
Address:
_____________________________________________________________________
City:
____________________________
State:_______ Zip:_____________________
Phone: Home (______)_____-________________
Work:(______)_____-___________________
E-mail address: ___________________________________________________________________
[ ]
I prefer to send/receive communications by e-mail rather than be regular mail.
VEHICLE INFORMATION (Attach Copy of Your Bill of Sale or Lease)
2.
Manufacturer: ______________________________________________________________________
(GM, Ford, Chrysler, Toyota, Winnebago, etc.)
3.
Year: ______________________
Model: ____________________________________________
4.
Did you purchase or lease your wheelchair in New York? ....................
Yes[ ] No[ ]
5.
Purchase Price: $ __________________
6.
Did you lease your wheelchair? .............................................................
Yes[ ] No[ ]
7.
Monthly lease payment: $ __________________; Total paid under lease: $ ___________________
8.
Date of delivery: __________________
9.
Do you still own or lease your vehicle? ........................................
Yes[ ] No[ ]
10.
Was the wheelchair paid by:
[ ] Medicaid
[ ] Medicare
[ ] other: _____________________
1
DEALER INFORMATION
11.
Name:
_____________________________________________________________________
Address:
_____________________________________________________________________
City:
_______________________ State:___________ Zip:_________________________
LEASING COMPANY (if leased):
12.
Name:
___________________________________________________________________
Address:
___________________________________________________________________
City:
_______________________ State:_____________ Zip:_____________________
Lease Acct #: ____________________________________________________________________
WHEELCHAIR'S PROBLEM(S)
13.
Briefly describe the existing problem(s) for which you now seek a relief:
__________________________________________________________________________________
________________________________________________________________________________
14.
(a)
What date did you first report this problem(s) to the dealer or the
manufacturer?__________________________
(b)
Did you make the wheelchair available for repair before one year
after the first delivery? __________________
BASIS FOR RELIEF SOUGHT:
To qualify for relief, you must complete
either question 15 or 16.
15.
Three or More Unsuccessful Repair Attempts
(a)
Were there three or more unsuccessful repair attempts for the
same problem within one year from the date of original delivery? … Yes[ ] No[ ]
(b)
Does the problem continue to exist? ……………………………..…
Yes[ ] No[ ]
(c)
Give the date and work order number for each of the three repair
attempts by the dealer for the same problem and attach copies of them.
If you do not have copies of the work orders, once accepted into the Program,
you may request copies from the manufacturer, with the arbitrator's approval,
by writing the Administrator pursuant to Regulation '301.9.
2
Problem (Specify): ___________________________________________________________
Date
Work Order #
(1)
____________________
____________________
(2)
____________________
____________________
(3)
____________________
____________________
16.
Days in Shop for Repairs
(a)
Was the wheelchair out of service within the first year for the total
of 30 or more days? …………………………………………
Yes[ ] No[ ]
(b)
List the dates your wheelchair was out of service:
From: ____________ To: ____________ Days out: ____________
From: ____________ To: ____________ Days out: ____________
From: ____________ To: ____________ Days out: ____________
HEARING LOCATION
17.
Please indicate where you want the arbitration hearing to be held:
[ ] Highland
[ ] Oswego
[ ] Albany
[ ] Hudson
[ ] Penn Yan
[ ] Amsterdam
[ ] Ilion
[ ] Plattsburgh
[ ] Auburn
[ ] Poughkeepsie
[ ] Batavia
[ ] Ithaca
[ ] Rochester
[ ] Binghamton
[ ] Jamaica
[ ] Saratoga Springs
[ ] Bronx
[ ] Jamestown
[ ] Brooklyn
[ ] Johnstown
[ ] Schenectady
[ ] Buffalo
[ ] Lake Placid
[ ] Smithtown
[ ] Canandaigua
[ ] Lower Manhattan
[ ] Speculator
[ ] Carmel
[ ] Lowville
[ ] Staten Island
[ ] Catskill
[ ] Lyons
[ ] Syracuse
[ ] Cobleskill
[ ] Malone
[ ] Troy
[ ] Corning
[ ] Monticello
[ ] Upper Manhattan
[ ] Cortland
[ ] Montour Falls
[ ] Utica
[ ] Delhi
[ ] New City
[ ] Waterloo
[ ] Elmira
[ ] Niagara Falls
[ ] Watertown
[ ] Fort Edward
[ ] Norwich
[ ] Yonkers
[ ] Geneseo
[ ] Ogdensburg
[ ] Glens Falls
[ ] Olean
[ ] Goshen
[ ] Oneida
[ ] Hempstead
[ ] Oneonta
3
TYPE OF HEARING AND RELIEF REQUESTED
18.
[ ] Oral
(a) in person …….
[ ]
(b) by telephone ...
[ ]
[ ] Documents only (if manufacturer agrees)
19.
If successful, I wish to receive a:
[ ] full refund
[ ] comparable new replacement vehicle
PREVIOUS ARBITRATION
20.
A.
Did you participate in any previous arbitration for the
same problem(s) for which you now seek arbitration?......
Yes [ ] No [ ]
B.
If yes, what was the name of the Program? __________________________________________
C.
Did you accept the decision of the arbitrator? ...............
Yes [ ] No [ ]
D.
Did the manufacturer comply with the decision?.............
Yes [ ] No [ ]
E.
Date of Decision: ________________________ (attach copy of decision)
SIGNATURE: __________________________________________Date: __________________________
CFB009 - (rev. 6/19)
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