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Agreement No.: IND-

GAP

Name:

Fax:

Phone:

Address:

City:

State:

Zip:

M.S.R.P.

Original Contract

Term

APR%:

Date:

(Months):

Year:

Make:

Model:

Mileage:

DEFICIENCY WAIVER ADDENDUM

  • Installment Sale Contract Loan Lease Other

COVERED VEHICLE INFORMATION

  • New

Dealer #

VIN#:

DEALER INFORMATION

Amount Financed/ Capitalized:

  • Used

  • GAP BROAD FORM

ENROLLMENT CHARGE $

________________

LENDER / LESSOR INFORMATION

Name:

Fax:

Phone:

Address:

Finance Agreement #

City:

State:

Zip:

CUSTOMER INFORMATION

Last Name:

First Name:

Middle Initial:

Phone:

Address:

City:

State:

Zip:

YES, I ELECT THE GAP DEFICIENCY WAIVER ADDENDUM

I (CUSTOMER), WHOSE SIGNATURE APPEARS BELOW, ACKNOWLEDGE THAT THE INFORMATION CONTAINED ABOVE IS, TO THE BEST OF MY KNOWLEDGE, TRUE. I HAVE READ THE DEFICIENCY WAIVER ADDENDUM IN ITS ENTIRETY, AND AGREE TO ALL OF THE PROVISIONS HEREIN. THE PURCHASE OF THE DEFICIENCY WAIVER ADDENDUM IS VOLUNTARY AND IS NOT REQUIRED BY THE DEALER / ASSIGNEE TO OBTAIN CREDIT.

DATE:

CUSTOMER’S SIGNATURE:

DEALER’S SIGNATURE:

COVERAGE The named Customer is responsible to the named Dealer / Assignee under the terms of the described Financing Agreement for the amount of any early termination liability resulting from a Total Loss of the Vehicle. Due to this Addendum being in effect, the Dealer / Assignee agrees to cancel a portion of the Customer’s indebtedness in the event of a Total Loss of the Vehicle as defined herein.

The Deficiency Waiver Addendum will waive the amount equal to the Unpaid Net Balance less the Actual Cash Value (ACV) of the Vehicle, both as defined herein, subject to the ACV not having been reduced by more than $1,000 as a result of the application of the Customer’s primary insurance deductible (Customer’s primary insurance deductible will not be reimbursed where prohibited by law). Any deductible amount in excess of $500 remains the Customer’s responsibility. It is further agreed that the maximum claim payment is limited to $25,000.

DECLINATION OF DEFICIENCY WAIVER ADDENDUM

I DO NOT CHOOSE TO PURCHASE THE DEFICIENCY WAIVER ADDENDUM. I UNDERSTAND THAT BY NOT ACCEPTING THE DEFICIENCY WAIVER ADDENDUM I AM NOT ENTITLED TO ANY OF THE BENEFITS IN THE EVENT OF A TOTAL LOSS OF THE VEHICLE.

DATE:

CUSTOMER’S SIGNATURE:

DEALER’S SIGNATURE:

Rev 10/07

Administrator: See Reverse Side

GAP WAIVER IND

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