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Run: GAP Waiver Disclosure and Customer Acknowledgment Form

This GAP Waiver Disclosure and Customer Acknowledgment Form captures the waiver offer, pricing, refund-on-payoff terms, and signed customer acknowledgment in...

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Customer and Agreement Details

Customer Full Name (required)

Agreement or Account Number (required)

Vehicle or Collateral Description

Optional identifier such as year/make/model or other collateral description, if needed for your records.

Disclosure Date (required)

GAP Waiver Disclosure

Was the GAP waiver offered to the customer? (required)

I understand the GAP waiver is optional and not required to obtain financing or credit. (required)

This acknowledgment supports voluntariness and consent.

Yes No N/A

GAP Waiver Price (required)

Enter the disclosed price for the GAP waiver.

Pricing Frequency (required)

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? (required)

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. (required)

Yes No N/A

Customer Acknowledgment and Signature

I acknowledge that I received and reviewed this GAP waiver disclosure and understand the terms described above. (required)

Yes No N/A

I consent to the collection and storage of this acknowledgment for compliance and audit trail purposes. (required)

Collect consent only for the minimum necessary compliance record.

Yes No N/A

Customer Signature (required)

Signed Date (required)

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Email (required)

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