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Cancellation Request Form

Customer Details

First Name*
Last Name*
Email*
Phone*
Would you like to request expedited processing of this refund? Expedited refunds receive quicker processing based on the timeline selected.
Processing speed

Vehicle/Contract Information
VIN*
Date of Contract*
Date of Cancellation*
Mileage at time of cancellation*

Reason for Cancellation

Select why you are canceling the contract and then upload the required document by selecting ‘Upload document’
Other
Upload Document

Type of Contract

Upload Contract (Optional)
Please select the type of contract to cancel*

Cancellation Refund Details

Address*
Street Address Address Line 2 City State ZIP Code
Do you still have an outstanding loan or lease?
- Yes
- No

I agree to the Terms of Cancellation

Customer Signature
- By selecting the checkbox, I certify that this is my digital signature and I agree to the terms and conditions of the service cancellation
- By selecting the checkbox, I acknowledge that:
- - The refund process can take up to 45 days, from the time your completed cancellation paperwork is received.
- - If any information is incorrect or missing, I agree to be contacted at the preferred method above. No refund will be issued until I have provided complete and correct documents and information.
- - The refund will be prorated and is paid to the lien holder if applicable and not to me.
- - I will no longer have this service product after I submit the cancellation.

Your Phone
This field is for validation purposes and should be left unchanged.

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Your Mercedes-Benz Dealer in North Haven, CT 41.4215769, -72.8386389.