Customer Waiver Cancellation Request - …

1 Express Autogap Customer Waiver Cancellation Request Please complete the following and mail or fax to our office (949) 727-0393 for Cancellation of the Express Autogap Waiver . Express Autogap Waiver Number Date of Sale Consumer Dealership Address Address City State Zip City State Zip Year Make Model VIN Current Mileage Cancel Effective: / / Lender/Lessor Installment Sale Contract/Loan Term (Months) Lease Address Reason for Cancellation .

2 (please check one) Sale Unwind Repossession Vehicle Traded Customer Request The GAP Waiver is non-cancellable after a total loss. Cancellations are processed according to the terms on the contract. Request submitted by: Dealership/Lender/Lessor Consumer(s) _____ _____ By Date Consumer Signature Date _____ _____ Title Co-Consumer Signature Date Portfolio, 11 Vanderbilt, Irvine, CA 92618 Telephone (800) 705-4001 Form GAPC ancel Revision 10/13