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>>>>)EJ STANDARD WARRANTY CLAIM ADJUSTMENT NO.G 4 6 g <br /> YOKOHAMA _ <br /> CLAIM FORM '" "� �" <br /> fOKOHAMA TIRE CORPORATION <br /> MACARTHUR PLACE,SUITE 800Y-`SANTA ANA, CA 92707 <br /> ;ONSUMER AFFAIRS(800)722-9888 . <br /> DOTE: DEALER MUST COMPLETE ALL NON-SHADED AREAS. SHADED AREAS ARE FOR YOKOHAMA USE ONLY. <br /> DEALER NAME ASSOCIATE DEALER OR NATIONAL ACCOUNT NAME CUSTOMER NAME END USER <br /> STREET ADDRESS STREET ADDRESS STREET ADDRESS <br /> CITY, STATE,ZIP CODE <br /> CITY, STATE, ZIP CODE CITY, STATE,ZIP CODE <br /> PHONE NUMBER <br /> YOK IA DEALER NUMBER CLAIM DATE' % NATIONAL ACCOUNT NUMBER(IF APPLICABLE) E-MAIL ADDRESS <br /> M9. DA/ ,YEAR _ <br /> ORIGINAL EQUIPMENT VEHICLE YEAR MAKE MODEL POSITION OF CLAIM TIRE(S) NOTICE tb DEALEA <br /> ❑YES ❑NO I (Please check and indicate item number) If claim is disallowed, the product will be scrapped <br /> VEHICLE MILEAGE DATE VEHICLE PURCHASED (IF O.E.) FRONT FRONT unless the box below is checked. <br /> __❑ _❑ F-1 RETURN FREIGHT COLLECT <br /> VEHICLE IDENTIFICATION NUMBER (IF O.E.) CUSTOMER NOTICE <br /> ❑❑&= Read Carefully Before Signing <br /> COMPLETE FOR MILEAGE CLAIMS ONLY(Attach mileage certificate(s)) ❑❑-9-❑❑ I hereby certify that to the best of my knowledge the foregoing statements are correct, <br /> that I am the owner of the product presented for claim and that the product described <br /> ODOMETER AT TIRE REMOVAL was not involved in any accident,personal injury,consequential damage or other loss. <br /> accept credit in lieu of further claim. I understand that the tire(s), detailed on this <br /> ODOMETER AT TIRE INSTALLATION CAR ❑❑--❑❑ claim,become the property of Yokohoma Tire Corporation. <br /> =P= <br /> TOTAL MILEAGE RECEIVED TRUCK CUSTOMER SIGNATURE DATE <br /> MORMON <br /> tt •� _ '�-• •t t 8 <br /> .277 <br /> 3 Iq <br /> v/ <br /> W D U YTC l" ���CA't'SEEiVIt� rFIIILIVI"/��IVB [,ATS YY-1712'Z���UKI �`�k�I1 I�SUAL DATE <br /> ® = t //6 f <br /> M-91-1014 ' DEALER <br />