Campaign - Water Infiltration At the E.C.U. (Engine Control Module) (page 3 of 3)

Administrator National Highway Traffic Safety Administration Washington, DC 20590

Auto Safety Hotline:

1-800-424-9393 (Washington area residents: (202)366-0123).

We sincerely apologize for any inconvenience that you experience as a result of this recall. Thank you very much for your cooperation in this matter. 
We hope that your Yugo ownership experience will be otherwise long and satisfying.

Claim Form

CAMPAIGN NO.: 91V130

R/O CTL NO.:

DATE:

OWNER'S NAME: __________________________

ADDRESS:

________________________

CITY:

______________________________       STATE: __     ZIP:______-____

TELEPHONE:

(___) ___-____

DEALER TEL. NO.: (___) ___-____

DEALER NAME: _____________________________

YEAR:

__   MODEL: ___   VIN:_____________________   MILEAGE: __________

***** DO NOT SUBMIT THROUGH T.E.C. - MUST MAIL TO YUGO AMERICA, INC *****

ALL INFORMATION MUST BE FILLED IN TO RECEIVE WARRANTY REIMBURSEMENT

REPAIR COMPLETED:

__/__/__                 REPLACED ___ GROMETS PART NO. 2923

BY DEALER (CODE): __-____

OWNER'S SIGNATURE: ________________________________________________  DATE: __/__/__

DEALERSHIP'S SIGNATURE: ___________________________________________  DATE: __/__/__

NOTE

IF YOU ARE NOT THE PRESENT OWNER, PLEASE INDICATE VEHICLE STATUS:

__ TOTALED

 __STOLEN

__ OTHER : _____________________________________

SOLD TO

NAME: __________________________________________

ADDRESS:^?12G______________________________________________

CITY:

_________________________________ STATE: __  ZIP: _____-____