Transcription of Cancellation Request 2.24 - Extended Protection Plan
1 Cancellation Date: Cancellation Request Contract Number Vehicle Identification Number (VIN) Dealer Information Dealer BAC# Dealer Name: Street Address: City, State, Zip Code: Customer Information Customer Name: Street Address: City, State, Zip Code: Extended Protection Product Cancellation Cancellation Date* (Check All That Apply) Month Date Year GAP Tire and Wheel Pre Paid Maintenance Cancellation Mileage* Protection plan (VSC) *An Odometer or notarized statement indicating the odometer reading on the date of the Request will be required. Reason for Cancellation (Check One) Sale Unwound (Customer Signature Not Required if Within 60 Days of Contract Sales Repossession Vehicle Totalled Customer Request Other Customer Signature Date Authorized Dealer Representative Date Dealer: Please attach Contract Registration Page to this form and fax to 877 264 9705; or email to AMT Warranty Corporation, PO Box 927, Bedford, TX 76095)
