EFTA00311381.pdf

lath tail INUIl With iu Mercedes-Benz Premier Prepaid Maintenance Application for - Coverage Mercedes-Benz DARREN K INDYKE PLLC 56113 MERCEDES-BENZ MANHATTAN, INC. Purchaser Last Name Frst Dealer Code Dealer Name 575 LEXINGTON AVE FL 4 MERCEDES-BENZ MANHATTAN, INC. Address D/B/A NEW YORK NY 100226146 NEW YORK NY City State Zip one Dealer City State Llenholder Name Address City State Zip Phone ML350W4 ML350W4/2015 New Vehicle Retail Date Model Model Year Vehicle Identification Number Original New Vehicle In-Service/Warranty Start Date: Month Day Year Current Mileage 12 Agreement Type/Term' Premier40K NPPMS- Purchase Price S 1,825 CO + Sales Tax S 161.97 = Total Purchase Price $ 1,986.97 4YR Agree nd Date: Day Year (rai ✓ 05/15/2015 THERESA INGANNAMORTE 05/15/2015 Cusco nature Dale Dealer Representative Signature Rep Name Date V This checkmark indicates you are providing the equivalent of your signature and indicating your intent to enter into this agreement upon acceptance. EFTA00311381