P.O. Box 2400 CANCELLATION REQUEST Mountain Home, AR 72654 RETURN VIA FAX TO 870-424-6618 1.800.264.5090 EMAIL
[email protected] www.ascwarranty.com
Cancellations can be processed by submitting a copy of the service agreement and this form.
Service Agreement Number: ___________________________________ Customer Name:
___________________________________ Vehicle Information
Year:_______ Make:_______________ Model:________________ Vin#:__________________________________________________ Cancellation Date:
___________________________________
Mileage at Cancellation:
___________________________________
Reason for Cancellation:
___________________________________ ___________________________________
___________________________________________________________________________ Send Refund to:
___________________________________ ___________________________________ ___________________________________ ___________________________________
____________________________________________________________________________ Notary Public:
___________________________________
My Commission Expires:
___________________________________
PLEASE NOTE THAT ALL CANCELLATION REQUESTS MUST BE NOTARIZED
