Simply replace the unfilled areas such as "__" and "_[date]_" with your information.
We are sorry to hear that you have been experiencing problems with your new [name of product].
While we do ask that our customers contact their dealer in the event of a problem, we recognize that, in your case, this is not possible. Please mail the product to [address] for service.
Again, we are sorry that you experienced this difficulty and wish to thank you for your patience and for purchasing [name of product].