Cancellation Request 2.24

[Pages:1]Date:

Contract Number

CANCELLATION REQUEST

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

(Check All That Apply)

GAP Tire and Wheel Pre-Paid Maintenance Protection Plan (VSC)

Cancellation Date*

Month

Date

Year

Cancellation Mileage*

*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 programsupport@. AMT Warranty Corporation, PO Box 927, Bedford, TX 76095

Cancellation Request_2.24.15

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