Consumer Mediation Services - Mediation Request Form

If you experience issues completing this form online, please find the form here: NMVB Form Samples and email it to .

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Contact Information

Please enter your contact information. Fields with '*' are required.

First Name

First Name is required

Last Name

Last Name is required

Address

Address is required

City

City is required

State

State is required

Zip Code

Please enter a valid ZIP code

Telephone

() -

Please enter a valid phone number

How did you hear about us?

Please select how you heard about us

Please enter a valid email address

Confirm Email

Email addresses do not match

Vehicle Information

Make

Make is required

Model

Model is required

Year

Please enter a valid year (1900-current)

Current Mileage

Current Mileage is required

Purchase/Lease Information

Date of Purchase/Lease

Purchase date is required and cannot be in the future

Purchase or Lease

Purchase Lease

Please select Purchase or Lease

Mileage at Purchase/Lease

Purchase mileage is required

Vehicle Condition at Purchase

New Used

Please select vehicle condition

Type of Warranty on Vehicle

Manufacturer Extended None

Please select at least one warranty type

Dealer Information

Please enter information about the dealer where you purchased your vehicle. All selling dealer fields are required.

Selling Dealer

Dealer Name

Dealer Name is required

Address

Address is required

City

City is required

State

State is required

Zip Code

Please enter a valid ZIP code

Telephone

() -

Please enter a valid phone number

Service Dealer (Optional)

Same as the selling dealer

Dealer Name

Address

City

State

Zip Code

Telephone

() -

Written Notice and Repair Information

Have you given written notice of defects to manufacturer?

Yes No

Please select Yes or No

Has manufacturer (or designated agent) attempted repairs?

Yes No

Please select Yes or No

Complaint Details

Please use the field below to enter details about your complaint:

Please provide details about your complaint

What are you seeking as a resolution to your complaint?

Please specify what resolution you're seeking

Review Your Information

Personal Information

Name:

Address:

City:

State:

Zip Code:

Phone:

Email:

Vehicle Information

Make:

Model:

Year:

Current Mileage:

Purchase Date:

Purchase Type:

Vehicle Condition:

Purchase Mileage:

Warranty Type:

Dealer Information

Selling Dealer

Name:

Address:

City:

State:

Zip Code:

Phone:

Service Dealer

Name:

Address:

City:

State:

Zip Code:

Phone:

Complaint Information

Written Notice Given:

Repairs Attempted:

Complaint Details:

Expected Resolution:

How you heard about us:

IMPORTANT NOTICE:

I voluntarily consent to the New Motor Vehicle Board's release of personal information contained in this form to the dealer(s), manufacturer, distributor, or other parties named herein for the purposes of mediating this dispute and until such time as the complaint is resolved or I withdraw my consent.

Section 20 and 3000 of the California Vehicle Code make it unlawful to use a false or fictitious name or knowingly make false statements or knowingly conceal any material fact in any document filed with the New Motor Vehicle Board.

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Click "Submit" to complete your request. A copy of your completed form will be sent to the email address provided.