WTY013_REIMB_AM

REQUEST FOR REIMBURSEMENT FORM
2012-2013 MY Soul Vehicles
Motor Driven Power Steering (MDPS) Flexible Coupling
Warranty Extension Program (WTY013)
If you have incurred expense to remedy this issue prior to the date of this notice, you may have the opportunity to
obtain reimbursement for that expense. You may submit your receipts online to Kia via the Owners section of
www.kia.com or mail your receipts with a cover letter directly to Kia for review and consideration:
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: ________________________________________
WTY013