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Last Name:    First Name:
Address:
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Home Phone:    Work Phone:
E-mail Address:
Retailer Name:
Retailer Address:
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Retailer Phone:
Plan Name:    Plan Numbers:
Furniture Category (check one)     Fabric   Leather   Case Goods   Mattress
Piece of Furniture (ie: sofa, dining table, bed, sectional)
Location of Stain/Damage
SKU Number (From Invoice)
Date damage occurred	Date delivered
Did you attempt to clean/repair the damage?  Yes   No If yes, what did you use?  What was the result?
Explain, in detail, the stain/damage that you are reporting.
Explain, in detail, how the stain/damage occurred:
Additional Comments:

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