Agreement Number:

Selling Dealership:

Customer:

VIN:

Sold: Miles at time of sale:

Expires on: or at Miles

Date of Cancellation:

Cancellation Effective Date:

Odometer at Cancellation:

Original Retail Selling Price:

Refund Percentage:

Cancellation Fee:

Amount Due Customer:

Reason For Cancellation:

Refunded by Dealership to: Lienholder Customer Trade In I hereby request cancellation of this Agreement identified above. In consideration of such cancellation, I, do hereby release and forever discharge the Company from any and all liability with respect to the Agreement so cancelled and do further agree to hold harmless the Company from any and all claims, demands, actions and payments on the account of the Agreement so cancelled, except for the refund of the premium. Signed:

Customer Signature (Please Print Name) Date

Signed:

Authorized Dealer Representative (Please Print Name) Date

* A copy of the check made payable to the customer and /or lienholder must be attached to this form for prompt processing 2016 NISSAN JUKE S

JN8AF5MR9GT610016

11/06/2022 61,610

02/06/2106 90,000

$394.95

$-50.00

$279.12

12/15/2023

QCSRJ611271

STEVEN CORREA-LAWSON

83.333 %

12/15/2023

70,667

Customer Request

HENDRICK CHRYSLER DODGE JEEP RAM FIAT OF CONCORD

Cancellation – Dealer Refund

Contract Number:

Customer:

Amount Due Dealer:

Cancellation Percentage:

Date of Cancellation:

Odometer at Cancellation:

Reason for Cancellation:

Trade-In Total Loss Repo Sold Vehicle Customer Request

'03 3&'&3 163104&4 0/-:

-FOEFS /BNF

1BJE $MBJNT

QCSRJ611271

STEVEN CORREA-LAWSON

$195.62

83.333 %

12/15/2023

70,667

Customer Request

FIFTH THIRD BANK, N.A.

$0.00

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