MASABA WARRANTY CLAIM FORM

							                                                              WARRANTY CLAIM FORM
1617 317th Street, PO Box 345, Vermillion, SD 57069           DATE OF CLAIM:
Tel: (605) 670-2567     Fax: (605) 624-89                                                 M /     D /   Y
www.MASABAinc.com

          DEALER NAME AND ADDRESS                     EQUIPMENT DESCRIPTION:

                                                      S/N:                               HRS:

                                                                                         YEAR:

                                                      DEALER CONTACT INFO:
          OWNER NAME AND ADDRESS
                                                              DATE OF FAILURE:                   DATE OF REPAIR:




DESCRIPTION OF FAILURE




                                          PART DESCRIPTION
QTY.       PART #                                 DESCRIPTION                             COST/EACH         TOTAL $




                                                                                          PARTS TOTAL

                                ITEM DESCRIPTION                                 HOURS          RATE        TOTAL $




                                                                                         TOTAL CLAIM :
THIS CLAIM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.



Warranty Claim Writer                    DATE

                                       FOR MASABA MINING EQUIPMENT USE ONLY
COMMENTS:
REASONS FOR DENIED WARRANTY