LEMON AUTO INTAKE FORM 
DATE______________
Your Information	
Name (full legal)		
Residence address
		
City State Zip 		
Resident of this State Since what date 		
Your Social Security Number		
Home phone #		
Work phone #		
Pager/fax #		
Your line of Work or Job		
Your employer		
Your Email Address 		
Lien Holder Account Number Lender Phone Address
 		
Date and place of Purchase		
Purchase Price		
Amount of Down Payment		
Pay off good for 60 days 		
Amount of payments you have made No. Payments x amount 		
Current Mileage		
Have you made any changes to the car??		
Is it Damaged?? 		
Dealership where you purchased the car		
Manufacturer		
Model of Car		
Vin Number 		
What are the Car’s Problems 

Condition of the Car?		
Have you found any TSB Technical Service Bulletins on the Car’s safety performance or value		
Has it caused any accident or injury ??  		

OTHER COMMENTS

I will need a copy of the following information 
1  Copy of Your Warranty
2  Copy of your car title, registration and Vin Number 
3  Copy of your finance agreement 
4  Copy of your Buyers agreement 
5  Copy of all service tickets
6   I will also need a release for information allowing us to get the payoff amount from your bank. 
I will need the name of your bank address phone number and your account number for this
7 The mileage of the car.  

Attached is a copy of my standard contract for your review or it is available for download on my site.
If you have any questions please call.  
Please fill out the intake form and our interview will be much faster
If you send me a completed intake form within 2 or 3 days prior to your appointment I will try to have your complaint already drafted for your review at the interview.  

If you are in Kentucky we will or we may file a lawsuit.  
If you case is against a foreign manufacturer or Ford and we may ask you to pay a small filing fee.  If your case involved GM or Chrysler we may directly submit your claim to the manufacturer.

If you are outside Kentucky we can directly negotiate claims with Chrysler and GM regardless of what state you are in
However,  
1.	We do not practice law outside Kentucky or the Federal Court in Southern Indiana.  We are only licensed to practice law here. Even in Southern Indiana we normally limit ourselves to Bankruptcy matters. 
2.	We do not travel to other states to practice law or make appearances in any state we are not licensed in
3.	We only negotiate directly with the manufacturer for you we do not provide any advise about the law in your state if you are from a state outside Kentucky or Indiana
4.	You may need or want to consider the advise of a local attorney in your state.  If we contract with you to represent you we will require you to sign that you understand that we only are negotiating for you and that we do not act as attorneys outside our home state. 

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Clients Signature