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CANCELLATION FORM

ALL CANCELLATIONS ARE FINAL - COVERAGE CANNOT BE REINSTATED AFTER CANCELLATION

SELLING DEALER IS RESPONSIBLE FOR ALL REFUNDS ALLOW FOUR TO SIX WEEKS FOR PROCESSING
Customer Signature:
Date:
Dealership Signature:
Date:
Submitted by:
Title:

I understand that by cancelling this option agreement I will no longer be eligible for 4000more.com Pre Set Buy Back Price. I waive all rights and I release 4000more.com of any financial responsibility. All refunds are first applied to the load or lease balance and will be sent directly to your lending institution. Refunds will not result in lowering your monthly payment.

ALL CANCELLATIONS ARE FINAL
COVERAGE CANNOT BE REINSTATED FOR ANY REASON

Contract Information
Vin Number:
Contract Start Date:
Cancellation Date:
Contract Term:
ONE YEAR
THREE YEAR
FIVE YEAR
Vehicle Information
Vehicle Year:
Vehicle Make:
Vehicle Model:
Reason for Cancellation
Customer Request
Voided Sale
Repossession
Total Loss
Other (Please Explain)
Customer Information
Customer Name:
Customer Address:
Customer Phone:
Customer Email:
Dealership Information
Dealership Name:
Dealership Address:
F&I Manager Name:
Dealership Phone:
Lien Holder Name:
Lien Holder Address:
SELLING DEALER IS RESPONSIBLE FOR ALL REFUNDS ALLOW FOUR TO SIX WEEKS FOR PROCESSING
Refund Information
Days in effect:
Retail Price
$
Remaining days:
Cancellation Fee (if applicable)
$
Earned factor:
Lien Holder / Customer Amount
$
Unearned factor:
4000more.com Chargeback
$
Mail or email to:

4000more.com, Attn: Cancellations
70 Suffolk Ct., Ste 400
Hauppauge, NY 11788
Toll Free: (844) 934-6673
Email: info@4000more.com, Subject: Cancellations