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ICLE IDENTIFICATION NUMBER SECTION II CREDIT UNION NAME MEMBER(S) ACCOUNT NUMBER SECTION III DATE OF CANCELLATION MILEAGE AT CANCELLATION REASON FOR CANCELLATION SECTION IV I hereby request cancellation of this Mechanical Repair Coverage Agreement/Policy. In consideration of such cancellation, I, do hereby release and forever discharge the Company from any and all liability with respect to the Agreement/Policy so cancelled and do further agree to hold harmless the Company from any and all.

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