Transcription of Cancellation Request Form - American Financial …
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Cancellation Request Form - American Financial …
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 WR
Rev 3/17/16 Customer Name: Selling Dealership: Address: Dealership Contact Name: City, State Zip: Dealership Phone Number:
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