1 Cancellation form Customer's Name: Address: City: State: Zip: Telephone: E mail address: Contract Purchase Term of Months in Date: Contract: Effect: Cancellation / Mileage on Cancellation / Repo Date: Repo Date: VIN: Year: Make: Model: Lienholder: PRODUCT(S) TO BE CANCELLED Contract # REASON FOR Cancellation SERVICE CONTRACT Customer Request (Attach Odometer Statement, if applicable) GAP Trade In (Attach Odometer Statement, if applicable) ETCH Totaled/Stolen (Attach copy Ins. report) TIRE & WHEEL Repossession (Attach Lienholder request) STAR UVP Loan Paid Off Other: _____ Other: _____ I hereby request Cancellation of my service contract/agreement in accordance with the Cancellation terms and conditions of my service contract/agreement, and declare that the mileage herein is true and correct.
2 Contract Holder Signature: Date: The Cancellation form is to be submitted (when possible) to the provider where the contract was purchased. The provider will in turn submit the request to cancel to the program administrator ( Interstate National Dealer Services). The Administrator will cancel the agreement. You will receive your refund check directly from the provider. If a lien is outstanding against the contract, the provider will issue a check made payable to the lienholder. For quickest turnaround time, please email completed form to Interstate National 6120 Powers Ferry Rd. NW, Suite 200 Atlanta, GA 30339 IN_CANCEL 1/17 E mail: 800 942 0400 Fax: 678 894 3558.