Please Print before Submitting

First Name:

Last Name:

Address:

Apartment No.
and/or Name of
Complex:

Cross Street:

City:

State:

Zip Code:

County:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Damage to Merchandise:  

What Type of Repair?

What is the Item?

Who is the Manufacturer
of the Merchandise?

The Store where the
Furniture was Purchased:

What is the Style Number
or Serial Number?

What is the Sales
Check Number?

What is the SKU Number?

What is the Color Number?