OFFICE OF THE ATTORNEY GENERAL Lawrence G. Wasden
Consumer Protection Division 954 W. Jefferson, 2nd Floor P.O. Box 83720 Boise, ID 83720-0010 (208) 334-2424
IDAHO CONSUMER RESTITUTION CLAIM FORM: DELL INC. & DELL FINANCIAL SERVICES SETTLEMENT
Name: Address: City E-Mail State: Zip: Phone Number
1. In order to be eligible for restitution, your claim must involve a transaction with Dell Inc. or Dell Financial Services that occurred between April 1, 2005, and April 13, 2009.
Transaction Date:
2. In order to be eligible for restitution, your claim must involve a verifiable out-of-pocket monetary loss.
Loss Amount:
(please attach documentation in support)
3. In order to be eligible for restitution, your claim must concern a transaction about one or more of the following issues. Please check the box next to the issue(s) that best describes the subject of your claim: A Dell Financial Services Conditional Financing Promotion; A rebate that you applied for but never received; A warranty service that Dell did not perform as promised; and/or An extended warranty or next-day-business service that Dell did not provide as promised. Please describe your claim (attach additional sheets if necessary):
Print, Sign, and Mail Form
Date Signature