GAP Waiver Disclosure and Customer Acknowledgment Form

Discloses GAP waiver pricing, voluntariness, and refund-on-payoff terms, and captures customer acknowledgment and signature in a compliant, consumer-friendly format.

Customer and Agreement Details

• Customer Full Name
• Agreement or Account Number
• Vehicle or Collateral Description
  Optional identifier such as year/make/model or other collateral description, if needed for your records.
• Disclosure Date

GAP Waiver Disclosure

• Was the GAP waiver offered to the customer?
• I understand the GAP waiver is optional and not required to obtain financing or credit.
  This acknowledgment supports voluntariness and consent.
• GAP Waiver Price
  Enter the disclosed price for the GAP waiver.
• Pricing Frequency
• Pricing Explanation
  Use this field only if additional explanation is needed for the disclosed price or billing method.

Refund and Termination Terms

• Was the refund-on-payoff term disclosed?
• Refund Method
  Select the method used to calculate or apply any refund, if applicable.
• Refund and Cancellation Terms Summary
  Summarize the refund-on-payoff and cancellation terms disclosed to the customer.
• Customer questions were answered before signing.

Customer Acknowledgment and Signature

• I acknowledge that I received and reviewed this GAP waiver disclosure and understand the terms described above.
• I consent to the collection and storage of this acknowledgment for compliance and audit trail purposes.
  Collect consent only for the minimum necessary compliance record.
• Customer Signature
• Signed Date