Cancellation Form
Instructions:
Reason for Cancellation
Product To Be Cancelled:
1. Complete all information (incomplete forms will be returned unprocessed).
(Select One)
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Guaranteed Asset Protection (GAP)
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Lease Wear & Tear
2. Attached copy of customer’s original Contract. 3. Please, fax or mail to administrator: Cancellations Department 3500 Piedmont Road NE, Suite 400 Atlanta, Georgia 30305 FAX: 678-553-1374
[email protected]
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Customer Request Flat Cancellation Repossession (Must include Repossession letter from lienholder)
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Loan Paid Off
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Tire & Wheel Protection Vehicle Service Contract (VSC)* Other: _____________________
Other
4. Allow three to four weeks for processing.
Registered Customer’s Name Address City
State
ZIP
Phone Number
Dealer Name Last 7 Digits of Vehicle Identification Number (VIN) Contract Purchase Date Year
Cancellation/Repo Date Make
Model
Lienholder Term of Contract/Finance Agreement
Months in Effect
*
Additional Information Needed for Cancellation of Vehicle Service Contract (VSC)
Odometer on Purchase Date
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Odometer on Cancel Date
I hereby request cancellation of my agreement in accordance with the cancellation terms and conditions of my agreement. I realize I relinquish all rights and provisions.
Registered Customer Signature
Date
Dealer Signature
Date
Notes
Administrator Use Only
SGCNL
Rev 8/10
