CS1604FORM

REQUEST FOR REIMBURSEMENT FORM
2011-2013 and some 2014 MY Optima Vehicles
Motor Driven Power Steering (MDPS)
Customer Satisfaction/Warranty Extension Program (CS1604 /WTY006)
If you have paid to have the flexible coupling in the MDPS replaced, you may be eligible for reimbursement for some or
all of that expense. Mail this completed Request for Reimbursement Form to Kia, along with documentation specified
below, for review and consideration at the following address:
Consumer Assistance Center
Kia Motors America, Inc.
P.O. Box 52410
Irvine, CA 92619-2410
Please allow sixty (60) days for review and response.
Customer Name: ___________________________________________________________________
Customer Address: _________________________________________________________________
Customer City, State, Zip Code: ______________________________________________________
Daytime Phone: _______________________ Evening Phone: ____________________________
Vehicle Identification Number: __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ (17 digits)
Mileage at Time of Repair: _________________________ Date of Repair: _________________
Amount of Reimbursement Requested: $______________
Attach the following:
□ Repair Order showing:
• Name & address of person paying for the repair
• Vehicle Identification Number (VIN) of vehicle repaired
• Description of the problem repaired (e.g., replacement of the flexible coupling in the MDPS)
• Date of repair and mileage on the vehicle at the time of repair
• Total cost of repair expense being claimed
□ Evidence of Payment of Repair showing:
• Date of payment
• Amount paid (e.g., copies of cancelled check or credit card receipt)
I certify that the documents attached to this Request for Reimbursement are true and accurate and should be used as the
basis for a reimbursement to me under this Customer Satisfaction Program/Warranty Extension.
CLAIMANT’S SIGNATURE:
___________________________________________________
Signature
Print Name: ________________________________________
CS1604/WTY006