Cancellation Request Form

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Customer Name: ________________________________________ _____Selling Dealership:_____________________________ ____________________Address: ________________________________________ ___________Dealership Contact Name: ________________________________________ ___City, State Zip: ________________________________________ _______Dealership Phone Number:_________________________________ __________Contract Number: ________________________________________ ____Last 6 of VIN: ________________________________________ _____________Effective Cancellation Date: _____________________________________Cur rent Odometer (if applicable): _____________________________________Veh icle Year, Make, Model: ________________________________________ ________________________________________ __________________________Lienholder and Address: ________________________________________ ________________________________________ ____________________________Customer Request reason: ________________________________________ ______Contract Holder s Signature (Required)__________________Co-Buyer Signature_______Date_______Date / / / / / /_______________________________________ ______Dealer Representative Signature_______Date______________ Vehicle Service Contract (VSC)______________ Maintenance______________ GAP Waiver______________ Ancillary______________ Excess Wear & TearPLEASE INITIAL WHICH PRODUCT(S) YOU WISH TO CANCEL: Cancellation Request FormREASON FO

GAP CANCELLATIONS: YOU HAVE THE UNCONDITIONAL RIGHT TO CANCEL GAP FOR A FULL REFUND/CREDIT WITHIN THIRTY (30) DAYS AFTER IT IS ... am aware that I am responsible for providing written proof of lien release to the dealer if I have paid the loan in full on the covered vehicle. I, the above customer, am aware that if any products/services are ...

  Line, Release, Unconditional, Lien release