Transcription of Cancellation Request Form
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Cancellation Request Form
Customer Name: _____Selling Dealership:_____Address: _____Dealership Contact Name: _____City, State Zip: _____Dealership Phone Number:_____Contract Number: _____Last 6 of VIN: _____Effective Cancellation Date: _____Current Odometer (if applicable): _____Vehicle 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 FOR Cancellation :PLEASE READ AND INITIAL THE FOLLOWING ITEMS UPON REVIEW AND AGREEMENT:I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS AND AGREE TO THEM CANCELLATIONS: YOU HAVE THE unconditional RIGHT TO CANCEL GAP FOR A FULL REFUND/CREDIT WITHIN THIRTY (30) DAYS AFTER IT IS PURCHASED PROVIDED YOUR COLLATERAL HAS NOT SUFFERED A TOTAL LOSS, AND YOU COMPLETED AND RETURNED THIS FORM OR OTHER WRITTEN NOTICE OF Cancellation TO THE BELOW ADDRESS POSTMARKED NO LATER THAN THIRTY (30) DAYS AFTER GAP WAS PURCHASED.
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 ...
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