AWS-221 1001 r - totalwarrantyservices.com

1 customer COPYTHE LOWER PERCENTOF MONTHS OR TIMES customer CHARGE $..=GROSS REFUND$..LESS SERVICE CHARGE*$.. customer S REFUND$..CANCELLATION REQUESTT otal Warranty ServicesPO BOX 3948 West Palm Beach, FL 33402 SECTION I (Must Be Filled Out Completely)SECTION II (Must Be Filled Out Completely)SECTION III (Must Be Filled Out Completely)MONTHSMILESCONTRACT NUMBERCONTRACTPERIODVEHICLE YEARVIN: customer CHARGE:ODOMETER ATCANCELLATION:ODOMETER READINGON ISSUE DATE:MILES DRIVEN:UNUSED PERCENTAGE OF MILES FROMCANCELLATION FORMULA (SEE REVERSE SIDE):%DATE CANCELED:CONTRACT DATE:TIME ELAPSED:MONTHS ELAPSED:*UNUSED PERCENTAGE OF MONTHS FROMCANCELLATION FORMULA (SEE REVERSE SIDE):% *COUNT 16 DAYS OR MORE AS A WHOLE MONTH*See Customers Contract For Appropriate Service Charge FOR TERMINATIONREPOSSESSIONOTHER (REQUIRES CONTRACT HOLDER TO SIGN REQUEST FOR CANCELLATION)I hereby request cancellation of this Contract checked above and further identified in the Contract.

2 In consideration of such cancellation, I, do hereby release and forever discharge the Company from any and all liability with respect to the Contract socanceled and do further agree to hold harmless the Company from any and all claims, demands, actions and payments onaccount of the Contract so canceled, except for refund of (02/11)Applicable Contracts:TWS-ESC-001 (02/11)TWS-ESC-002 (02/11)TWS-ESC-003 (02/11)TWS-ESC-004 (02/11)TWS-ESC-005 (02/11)TWS-ESC-007 (02/11)TWS-ESC-009 (02/11)ATTACH customer S COPY OF CONTRACTHOME OFFICE COPY SECTION IVCLIENT COST=$..$..LOWER PERCENTAGE OF MONTHS OR MILESX_____% _____%PRO RATA COST=$..$..LESS SERVICE CHARGE* $..$..AMOUNT DUE FROM AWS=$..$..AWS USE ONLYCLIENT CALCULATION*See Customers Contract For Appropriate Service Charge LOWER PERCENTOF MONTHS OR TIMES customer CHARGE $.

3 =GROSS REFUND$..LESS SERVICE CHARGE*$.. customer S REFUND$..CANCELLATION REQUESTT otal Warranty Services PO BOX 3948 West Palm Beach, FL 33402 SECTION I (Must Be Filled Out Completely)SECTION II (Must Be Filled Out Completely)SECTION III (Must Be Filled Out Completely)MONTHSMILESCONTRACT NUMBERCONTRACTPERIODVEHICLE YEARVIN: customer CHARGE:ODOMETER ATCANCELLATION:ODOMETER READINGON ISSUE DATE:MILES DRIVEN:UNUSED PERCENTAGE OF MILES FROMCANCELLATION FORMULA (SEE REVERSE SIDE):%DATE CANCELED:CONTRACT DATE:TIME ELAPSED:MONTHS ELAPSED:*UNUSED PERCENTAGE OF MONTHS FROMCANCELLATION FORMULA (SEE REVERSE SIDE):% *COUNT 16 DAYS OR MORE AS A WHOLE MONTH*See Customers Contract For Appropriate Service Charge FOR TERMINATIONREPOSSESSIONOTHER (REQUIRES CONTRACT HOLDER TO SIGN REQUEST FOR CANCELLATION)I hereby request cancellation of this Contract checked above and further identified in the Contract.

4 In consideration of such cancellation, I, do hereby release and forever discharge the Company from any and all liability with respect to the Contract socanceled and do further agree to hold harmless the Company from any and all claims, demands, actions and payments onaccount of the Contract so canceled, except for refund of (02/11)Applicable Contracts:TWS-ESC-001 (02/11)TWS-ESC-002 (02/11)TWS-ESC-003 (02/11)TWS-ESC-004 (02/11)TWS-ESC-005 (02/11)TWS-ESC-007 (02/11)TWS-ESC-009 (02/11)CLIENT COPYSECTION IVCLIENT COST=$..$..LOWER PERCENTAGE OF MONTHS OR MILESX_____% _____%PRO RATA COST=$..$..LESS SERVICE CHARGE* $..$..AMOUNT DUE FROM AWS=$..$..AWS USE ONLYCLIENT CALCULATION*See Customers Contract For Appropriate Service Charge LOWER PERCENTOF MONTHS OR TIMES customer CHARGE $.

5 =GROSS REFUND$..LESS SERVICE CHARGE*$.. customer S REFUND$..CANCELLATION REQUESTT otal Warranty Services PO BOX 3948 West Palm Beach, FL 33402 SECTION I (Must Be Filled Out Completely)SECTION II (Must Be Filled Out Completely)SECTION III (Must Be Filled Out Completely)MONTHSMILESCONTRACT NUMBERCONTRACTPERIODVEHICLE YEARVIN: customer CHARGE:ODOMETER ATCANCELLATION:ODOMETER READINGON ISSUE DATE:MILES DRIVEN:UNUSED PERCENTAGE OF MILES FROMCANCELLATION FORMULA (SEE REVERSE SIDE):%DATE CANCELED:CONTRACT DATE:TIME ELAPSED:MONTHS ELAPSED:*UNUSED PERCENTAGE OF MONTHS FROMCANCELLATION FORMULA (SEE REVERSE SIDE):% *COUNT 16 DAYS OR MORE AS A WHOLE MONTH*See Customers Contract For Appropriate Service Charge FOR TERMINATIONREPOSSESSIONOTHER (REQUIRES CONTRACT HOLDER TO SIGN REQUEST FOR CANCELLATION)I hereby request cancellation of this Contract checked above and further identified in the Contract.

6 In consideration of such cancellation, I, do hereby release and forever discharge the Company from any and all liability with respect to the Contract socanceled and do further agree to hold harmless the Company from any and all claims, demands, actions and payments onaccount of the Contract so canceled, except for refund of (02/11)Applicable Contracts:TWS-ESC-001 (02/11)TWS-ESC-002 (02/11)TWS-ESC-003 (02/11)TWS-ESC-004 (02/11)TWS-ESC-005 (02/11)TWS-ESC-007 (02/11)TWS-ESC-009 (02/11)CANCELLATION FORMULAMILEAGE REMAINING CALCULATIONStep 1 Mileage as Indicated inMiles DrivenUnusedthe Contract Term (from front)=Mileage_____Step 2 Mileage as Indicated inUnused Mileage the Contract Term = Unused Mileage %_____TIME REMAINING CALCULATIONStep 1 Month as Indicated inMonths ElapsedContract Term (from front)= Unused Months_____Step 2 Months as Indicated inUnused Months Contract Term= Unused Time %_____*Disregard any month with 15 days or less, but count 16 days or more as afull month.