HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form. Agline Equipment WARRANTY CLAIM FORM 1600 N. Pearl Street, Carthage MS 39051 Phone: (601)-572-4237 IMPORTANT 1. Claim must be submitted within 30 days of failure 2. Fill out one claim form for each unit 3. Hold parts at Dealer for disposition instructions DATE(Required) MM slash DD slash YYYY (Required) First Last DEALER NUMBERDISTRIBUTOR OR DEALER NAME: First DISTRIBUTOR OR DEALER ADDRESS Street Address Address Line 2 City ZIP Code CUSTOMER NAME First Last CUSTOMER ADDRESS Street Address Address Line 2 City ZIP Code BASE UNIT OR ATTACHMENT THAT FAILEDMODEL #SERIAL#DATE OF PURCHASE MM slash DD slash YYYY DATE OF FAILURE MM slash DD slash YYYY ACRES/HOURS OPERATEDTRACTOR MAKE AND MODEL 2WD OR 4WD DATE OF REPAIR MM slash DD slash YYYY ATTACHMENTS ADDED DESCRIPTION OF FAILURE/REASON FOR CREDITDEALER SIGNATURE First Last PARTS REPLACED(ITEMS CHECKED MUST BE RETURNED TO FACTORY)PARTS REPLACEDQUANTITYPART NUMBERDESCRIPTION Add RemoveCOMPANY USE ONLYWARRANTY APPROVEDCHECKMARKAMOUNT Add RemoveWARRANTY LABOR (COMPANY USE ONLY)HOURS / DESCRIPTION RATE TOTAL TOTAL PARTS TOTAL LABOR TOTAL CREDITS TOTAL LABOR ALLOWANCE RETURN PARTS BY: UPS COMM CARRIER AGLINE TRUCK
