WARRANTY CANCELATION

Request For Warranty Or Gap Cancellation

*First Name

*Last Name

*Phone

*Email

Address

City, ST, ZIP

VIN

Year

Make

Model

Cancellation Miles (Need Proof)

Contact Effective Date:

Cancellation Date:

Contact Number

Reason For Cancellation

Customer Request

Loan Paid Off (Need Lien Release)

Trade-In (Need Purch. Agree.)

Total Loss (Need Document)

Refinanced (Need Notice)

Sold (Need Lien Release)

Repossession (Need Repo. Note)

Other

Customer Signature

Date

Business Manager Signature

Office Use

Deal Number

Stock Number

Customer Number

Orig. Bus. Man

Purchase Amount

Original Cost

Refund Amount

Refund Percent

Processed By

Date

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