Brake Shift Interlock Case Form

Please fill out this free brake shift interlock evaluation form so that we may see if you have a case and if we would like to file a lawsuit on your behalf. Filling out this form does not establish an attorney, client relationship. It is only a request. All information is kept private and confidential. Please fill out all the fields.
If you would prefer to talk to one of our legal assistants instead of submitting this form then you can call us National Toll Free at 1-800-828-4LAW or email us at pswalin@branchlawfirm.com.
This lawsuit is open to New Mexico residents only.

Full name:
Email:
Street address:
City:
State:
Zip:
Home Phone:
Work Phone:
Vehicle Make: Model: Year:

Vehicle was purchased from Dealership: Individual: Leased:

Date of Purchase

Please list any modifications to vehicle:

Please describe any problems with or repairs made on the vehicle:

Please describe/document regular vehicle maintenance (i.e. frequency of oil changes, brake pad replacement, tire rotation, fluid checks, etc.)

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