EPA VERR# 4192 

Received: March 28, 2011
EPA VERR# 4192 

Received: March 28, 2011
EPA VERR# 4192 

Received: March 28, 2011
EPA VERR# 4192 

Received: March 28, 2011
EPA VERR# 4192 

Received: March 28, 2011
	

		


	



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EPA VERR# 4192 

Received: March 28, 2011
	

		


	



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EPA VERR# 4192 

Received: March 28, 2011
(SEE REVERSE SIDE FOR APPLICATION FORM)

REIMBURSEMENT PLAN 

Requirements for Reimbursement

If you meet all of the following requirements, you are eligible to receive reimbursement under this plan: 

1. You own or have owned a 2009-2010 Mazda6 vehicles built between April 8, 2008 and February 8, 2010. 

2. You have paid for the inspection, repair or replacement of the fuel tank due to damage/crack in the tank. 

3. You have an original or legible copy of the paid repair order or invoice receipt showing: 

Description of the concern reported 

Inspection, repair or replacement of the fuel tank due to damage/crack in the tank 

Vehicle model and year, and vehicle identification number (VIN) 

Your name and address at the time of repair 

4. Mail this reimbursement application form in the enclosed envelope to: 

Mazda North American Operations 

Attn: Recall Reimbursement Dept 

P.O. Box 57085 

Irvine CA 92619-7085 

Procedure for Reimbursement Request

Once your vehicle has had the fuel tank inspected, repaired or replaced by an authorized Mazda dealer due to 

damage/crack in the tank, you may apply for reimbursement by doing the following: 

1. Complete the Reimbursement Application Form found on the reverse side of this page. 

2. Mail the Reimbursement Application Form with a legible copy of the paid repair order and/or invoice using the 

enclosed envelope. 

3. Retain copies of the paid repair order or invoice and this application form for your records. 

4. You will be reimbursed for the amount you have paid for the inspection, repair or replacement of the fuel tank due to 

damage/crack in the tank. 

If you wish to correspond with Mazda regarding this reimbursement plan, please write to the above address and refer to 

your vehicle identification number (VIN). 

Any reimbursement application form that is incomplete, illegible, or sent without the legible copy of the paid repair order 

or invoice will be returned for completion. If Mazda has any questions concerning your application for reimbursement, 

you may be contacted. Please allow 6-8 weeks for processing. 

EPA VERR# 4192 

Received: March 28, 2011
(SEE REVERSE SIDE FOR REIMBURSEMENT PLAN DETAILS)

REIMBURSEMENT APPLICATION FORM 

2009-2010 Mazda6 Fuel Tank Safety and Emission Recall 6211B 

(Please type or print) 

 

Name: 

 First Middle Last 

Address: 

 Street Address 

 

 City State Zip Code 

 Home: 

Phone Number: 

 Work: 

 

Vehicle Identification Number (VIN): 

 (17 digits in length) 

 

Total Amount of Reimbursement Requested: . 

 Dollars Cents 

General Release 

I am submitting to Mazda Motor Corporation (“Mazda”) a claim for reimbursement for all inspection, repair or 

replacement of the fuel tank performed to date in connection with damage/crack in the tank. The vehicle identification 

number (VIN) is: 

VIN: 

In exchange for Mazda’s payment of that claim, I hereby release Mazda, its agents, and its related entities from 

all claims for such inspection/repair costs. This release shall benefit Mazda and its authorized agent Mazda 

North American Operations, its regions/distributors (foreign and domestic), its authorized dealerships, and all 

their respective directors, officers, agents, employees, divisions, subsidiaries, and affiliated companies. This 

release shall bind my heirs, successors and assigns.

Dated: Signed: 

INSTRUCTIONS FOR GENERAL RELEASE DESCRIBED BELOW: 

Please read thoroughly 

Fill in vehicle identification number 

Sign the General Release (below) 

EPA VERR# 4192 

Received: March 28, 2011