Sample “Request For Arbitration” Form

PURPOSE: The attorney general administers provisions of the Wheelchair Lemon Law and Assistive Devices for Major Life Activity, sections 407.950 to 407.970, RSMo. The attorney general is required to establish regulations controlling the arbitration of disputes arising under these provisions. This rule specifies a sample Request for Arbitration form. MISSOURI WHEELCHAIR AND ASSISTIVE DEVICE LEMON LAW CONSUMER INFORMATION 1. Name:________________________________________________ Address:______________________________________________ City:_______________________State:______ Zip:___________ Phone: Home (____)___________ Work: (____)_____________ ASSISTIVE DEVICE INFORMATION (Attach Copy of Bill of Sale or Lease) 1. Type of Device: ________________________________________ (For example, Wheelchair or Hearing Aid) 2. Manufacturer: _________________________________________ 3. Year: ________ Model: __________________________________ 4. [ ] I purchased my assistive device [ ] I leased my assistive device 5. Did you purchase or lease your assistive device in Missouri? [ ] Yes [ ] No 6. Date of delivery? _______________________________________ 7. Do you still own or lease your assistive device? [ ] Yes [ ] No DEALER INFORMATION 8. Name: ________________________________________________ Address: ______________________________________________ City: ______________________ State: ______ Zip: __________ LEASING COMPANY (if leased) 9. Name: ________________________________________________ Address: _______________________________________________ City: ______________________ State: _______ Zip: __________ ASSISTIVE DEVICE PROBLEM(S) 10. Briefly describe the existing problem(s) for which you now seek relief: ________________________________________________________ ________________________________________________________ 11. (a) What date did you first report the problem(s) to the dealer or the manufacturer? _____________________________________ (b) Did you make the assistive device available for repair before one year after the first delivery? . . . . . . . . . Yes [ ] No [ ] 12. Were there one or more unsuccessful repair attempts within one year from the date of original delivery? . . . . Yes [ ] No [ ] 13. Does the problem continue to exist? . . . . . . .Yes [ ] No [ ] 14. Give the date and work order number for each of the repair attempts by the dealer or manufacturer 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. Problem (Specify) _____________________________________ Date Work Order Number (1) ___________________ ________________________ (2) ___________________ ________________________ (3) ___________________ ________________________ (4) ___________________ ________________________ 15. List the dates your assistive device was out of service: From: ___________ To: ___________ Days out: __________ From: ___________ To: ___________ Days out: __________ From: ___________ To: ___________ Days out: __________ From: ___________ To: ___________ Days out: __________ TYPE OF HEARING 16. [ ] Oral (a) in person . . . . . . . . . .[ ] (b) by telephone. . . . . . . . [ ] [ ] Documents only (if manufacturer agrees) RELIEF REQUESTED 17. If successful, I wish to receive a: [ ] full refund [ ] comparable new replacement device 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 dealer relating to such problem). DO NOT SEND ORIGINAL DOCUMENTS. Please enclose the filing fee of $50.00. Upon receipt of the filing fee, your claim will begin to be processed. NOTICE: The decision of the arbitrator under this program is binding on both parties. You may wish to consult an attorney before participating in this program. Sign below and return the completed form, together with your documents and the filing fee, to ________________________________. SIGNATURE: _____________________________ Date: _________ AUTHORITY: sections 407.965 and 407.970, RSMo 2000.* Original rule filed Jan. 27, 2003, effective Aug. 30, 2003. *Original authority: 407.965, RSMo 1995 and 407.970, RSMo 1995.